Med Surg

The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse?

1 Antacids coat the lining of the stomach. 2. Omeprazole will coat the ulcer to help it heal. 3. Sucralfate changes the acidity of fluid in the stomach. 4. Cimetidine results in decreased secretion of stomach acid. 4 Cimetidine and other histamine H2-receptor antagonists decrease the secretion of gastric acid in the stomach. Antacids neutralize acid in the stomach. Omeprazole inhibits gastric acid secretion. Sucralfate promotes healing by coating the ulcer.

The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy?

1. "Antacids will coat my stomach." 2. "Omeprazole will coat the ulcer and help it heal." 3. "Sucralfate will change the fluid in my stomach." 4. "The nizatidine will cause me to produce less stomach acid." 4 Nizatidine, a histamine H2-receptor blocker, is frequently used in the management of peptic ulcer disease. Histamine H2-receptor blockers decrease the secretion of gastric acid (HCL). Antacids are used as adjunct therapy and neutralize acid in the stomach. Omeprazole is a proton pump inhibitor. Sucralfate promotes healing by covering the ulcer, thus protecting it from erosion caused by gastric acids.

A client has had extensive surgery on the gastrointestinal tract and has been started on total parenteral nutrition (TPN). The client tells the nurse, "I think I'm going crazy. I feel like I'm starving, and yet that bag is supposed to be feeding me." Which is the best response from the nurse?

1. "Don't worry. Many others in your situation say the same thing." 2. "That is unusual. I wonder if the solution is being mixed correctly?" 3. "That is because the empty stomach sends signals to the brain to stimulate hunger." 4. "Maybe you should ask your primary health care provider about that; I've never heard of that before." 3 The stomach does send signals to the brain when it is empty to stimulate hunger. The client should be told that this is normal. Some clients also experience food cravings for the same reason. Options 1 and 4 will block the communication process. Option 2 will produce fear in the client.

A sexually active 20-year-old client has been diagnosed with viral hepatitis. Which statement made by the client would indicate a need for further teaching?

1. "I can never drink alcohol again." 2. "I won't go back to work right away." 3. "My close friends should get the vaccine." 4. "A condom should be used for sexual intercourse." 1 To prevent transmission of hepatitis, a condom is advised during sexual intercourse, as well as vaccination of the partner or close friends. Alcohol should be avoided for 1 year because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that the liver function has returned to normal. The client's activity is increased gradually.

A generally healthy 63-year-old man is seen in the primary health care provider's office for a routine examination. Which statement made by the client is most important for the nurse to follow up on?

1. "I check my stool yearly for occult blood." 2. "I have been following the balanced diet plan that the doctor gave me." 3. "Everyone in my immediate family has died from gastrointestinal cancer." 4. "I try to avoid overly hot or spicy foods because they give me heartburn sometimes." 3 The nurse should follow up on the statement about familial cancer. The client may have some anxiety that this will ultimately occur to him and the nurse should gather further data to understand the client's situation and to identify additional risk factors. Options 1, 2, and 4 identify appropriate client behaviors regarding the prevention and detection of gastrointestinal cancer.

The nurse is caring for a client with suspected esophageal stricture. Which statement from the client supports this diagnosis?

1. "I feel dizzy and sweaty after eating meals." 2 "I've been having trouble swallowing meat." 3. "I've been having episodes of shortness of breath." 4. "I need to be propped up on several pillows to sleep comfortably." 2 Esophageal stricture is the narrowing of the lumen of the esophagus. A stricture can arise as a complication of another gastrointestinal condition, such as gastroesophageal reflux disease (GERD) due to the growth of scar tissue in response to chronic inflammation. The narrowing of the esophageal lumen can cause dysphagia, or trouble swallowing. Therefore, option 2 is the correct answer. Dizziness and sweat after eating meals supports that the client may be experiencing dumping syndrome. Shortness of breath could refer to several different conditions, but is not related to esophageal stricture. The need to be propped up on several pillows to sleep comfortably could be indicative that the client is suffering from heart failure.

A client is seen in the ambulatory care office for a routine examination. Which statement by the client would be most important for the nurse to follow up?

1. "I just lost a family member to gastrointestinal cancer. 2. It's been over 18 months since I last had my prostate checked. 3. I have had a hard time following a low-sodium diet like I know I should. 4. I avoid overly hot or spicy foods because they always give me heartburn." 1 The nurse should recognize and follow up on the statement about familial cancer. The client may have some anxiety that this will ultimately occur to him, and the nurse should gather further data to understand the client's situation. Gathering data about the types of cancer, age, and sex of affected family members and the presence of other risk factors provides the needed information to initiate preventive education. Options 2, 3, and 4 require follow-up but do not have the priority that the correct option has.

A calcium supplement is prescribed for a client diagnosed with hypoparathyroidism in the management of hypocalcemia. The client arrives at the clinic for a follow-up visit and complains of chronic constipation, and the nurse reinforces instructions to the client about measures to alleviate the constipation. Which comment by the client would indicate a need for further teaching?

1. "I need to increase my daily fluid intake." 2. "I need to increase my intake of high-fiber foods." 3. "I need to increase my activity level as tolerated." 4. "I need to add 0.5 ounce of mineral oil to my daily diet." 4 Rationale:Clients taking antihypocalcemic medications should be instructed to avoid the use of mineral oil as a laxative because it decreases vitamin D absorption, and vitamin D is needed to assist in the absorption of calcium. Options 1, 2, and 3 are basic measures to alleviate constipation.

The nurse is teaching a client with nonalcoholic fatty liver disease about measures to manage the condition. The nurse determines the client has a need for further teaching if the client makes which statement?

1. "I need to keep good control of my blood sugar." 2. "I am looking forward to starting an exercise pro gram." 3. "An ideal weight loss goal is at least 10% of my body weight." 4. "I should stop taking my cholesterol medication as it puts stress on my liver." 4 The risk factors for nonalcoholic fatty liver disease (NAFLD) include obesity, diabetes, hypertension, and hyperlipidemia. These risk factors can contribute to increased fatty infiltrates being deposited in the liver. Therefore, controlling blood sugar, starting an exercise program, and losing 10% of body weight are good measures to help manage the condition. The statement "I should stop taking my cholesterol medication as it puts stress on my liver" prompts a need for client teaching, as the client should not stop taking a prescribed medication without first discussing with the primary health care provider (PHCP) first. Furthermore, hyperlipidemia is a contributing factor to nonalcoholic fatty liver disease.

Psyllium is prescribed for the client diagnosed with a cardiac disorder to facilitate defecation and prevent straining with bowel movements. The nurse reinforces instructions to the client regarding administration of the medication. Which statement by the client indicates an understanding of the use of the medication?

1. "I need to mix the medication with custard." 2. "I should mix the medication with a full glass of water." 3. "I should decrease the amount of fiber in my diet when I take this medication." 4. "I need to decrease my fluid intake following administration of the medication." 2 Metamucil is a bulk-forming laxative. It should be taken with a full glass of water or juice (not custard), followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. Both fiber in the diet and fluid intake should not be decreased unless specifically prescribed by the primary health care provider.

The nurse has given the client diagnosed with hepatitis instructions about post discharge management during convalescence. The nurse determines a need for further teaching if the client makes which statement?

1. "I should avoid alcohol and aspirin." 2. "I should eat a high-carbohydrate, low-fat diet." 3. "I should resume a full activity level within 1 week." 4. "I should take the prescribed amounts of vitamin K." 3 The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as aspirin and alcohol. If prescribed for prolonged clotting times the client should take vitamin K.

The nurse is providing discharge instructions to a client following hemorrhoidectomy. Which statement, if made by the client, indicates a need for further instruction?

1. "I should use a doughnut to relieve pressure while sitting down." 2. "I will let my doctor know if I notice any bleeding from the rectum." 3. "I may need an enema if I don't have a bowel movement in a few days." 4. "I will take my pain medication to reduce the discomfort with having a bowel movement." 1 The client should be taught not to use a "doughnut" or pressure relief ring because it actually can reduce blood flow to the area. The client should contact the surgeon if they notice any bleeding from the rectum, particularly if they are taking any anticoagulants or anti-platelet medications. If the client does not have a bowel movement within 2-3 days, they may need an enema but should consult with the surgeon before administering it. They should take pain medication as prescribed to reduce the discomfort with having a bowel movement following a hemorrhoidectomy.

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?

1. "I walk 1 to 2 miles per day." 2. "I need to decrease fiber in my diet." 3. "I drink 6 to 8 glasses of water per day." 4. "I have a bowel movement every other day." 2 Adequate dietary fiber is an important factor for improving bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of the fecal mass through the gastrointestinal (GI) tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.

The nurse is providing instructions to a client that has an esophagogastroduodenoscopy (EGD) ordered to confirm the diagnosis of esophageal stricture. Which statement by the client indicates a need for further teaching?

1. "I will be awake during the procedure." 2. "I should not eat anything 6 to 8 hours before the exam." 3. "If a stricture is found, it can be dilated during this exam." 4. "I should stop taking my daily aspirin several days before the exam." 1 Esophageal stricture can be managed with anti-reflux medications to prevent further damage to the esophageal mucosa, or with procedures to dilate the esophageal lumen. An EGD can be used to both confirm the diagnosis and treat esophageal stricture by dilating the narrowed lumen. During an EGD, a camera scope is passed down through the esophagus while the patient is under moderate sedation. Therefore, option 1 indicates a need for further teaching, as the client will not be awake during the procedure. The client is taught to remain nothing by mouth (NPO) 6 to 8 hours before the procedure to prevent aspiration. The esophageal stricture can be treated during the exam with a balloon to stretch the stricture. Depending on the client's comorbidities, the client should stop taking anticoagulant medications several days before the exam to prevent bleeding.

The nurse working in an outpatient clinic is providing teaching to a client on preventive measures for hemorrhoids. Which statement, if made by the client, indicates a need for further teaching?

1. "I will take a stool softener every day until it heals." 2. "I will use witch hazel pads to help with pain relief." 3. "I will sit or lie down throughout the day as much as I can." 4. "I will make sure to drink enough water throughout the day." 3 Hemorrhoids are usually managed conservatively, and a major focus is preventive measures. The client should be taught to avoid prolonged standing or sitting, to take a stool softener if necessary to soften the stool to make it easier to pass, to use witch hazel pads and other over-the-counter preparations for symptomatic relief, and to make sure to drink enough water throughout the day to prevent hard stools.

Which statement by the spouse of a client with diagnosed end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding management of the client's pain?

1. "If constipation is a problem, increased fluids will help." 2. "If the pain increases, I must let the doctor know immediately." 3. "This opioid will cause very deep sleep, which is what my husband needs." 4. "I should have my husband try the breathing exercises to help control pain." 3 Changes in level of consciousness are an indicator of potential opioid overdose and are indicative of numerous fluid, electrolyte, and oxygenation deficits. It is important for the spouse to understand the differences in sleep related to the relief of pain and changes in neurological status related to overdose or deficits. All remaining options are indicative of an understanding of appropriate steps to be taken in the management of pain.

The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. Which statement would the nurse make to the client for consideration?

1. "Lie down for at least an hour after eating." 2. "Be sure to sleep with your head elevated in bed." 3. "This problem requires surgery most of the time." 4. "Eat foods that are higher in fat to slow down digestion." 2 Most clients with hiatal hernia can be managed by conservative measures that include a low-fat diet, avoiding lying down for an hour after eating, and keeping the head of the bed elevated.

The nurse is reviewing concepts related to irritable bowel syndrome (IBS) with a nursing student. Which statement by the nursing student indicates there is a need for further teaching?

1. "There is no known organic cause of IBS." 2. "IBS is characterized by only episodes of diarrhea." 3. "Gluten and different kinds of saccharides can exacerbate symptoms." 4. "IBS can cause non-gastrointestinal (GI) symptoms such as headaches." 2 Irritable bowel syndrome (IBS) is characterized by chronic abdominal pain and altered bowel activity. The client may experience either diarrhea, constipation, or alternating episodes of diarrhea and constipation. Therefore, option 2 would prompt the nurse to further teach the nursing student about IBS. "There is no known organic cause of IBS," "Gluten and different kinds of saccharides can exacerbate symptoms," and "IBS can cause non-gastrointestinal (GI) symptoms such as headaches" are all correct statements.

The nurse is collecting physical assessment data for a patient with possible splenomegaly. The nurse should palpate which abdominal quadrant? Refer to figure.

1. 1 2. 2 3. 3 4. 4 2 The spleen is located in the left upper quadrant of the abdomen and can be palpated in the area. Therefore, the other options are incorrect.

The nurse is preparing to administer a soapsuds enema to a client. Into which position would the nurse place the client to administer the enema? Refer to figure.

1. A 2. B 3. C 4. D To administer an enema, the nurse assists the client into the left side-lying (Sims') position with the right knee flexed. This position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thus improving the retention of solution. Option 1 is a supine position. Option 2 is a prone position. Option 4 is a right side-lying (semiprone) position.

The client is to receive a soapsuds enema. Which is the best position for administering an enema? Refer to figure.

1. A 2.B 3.C 4.D The Sims, or left lateral, position is the position of choice for enema administration facilitating fluid to pass farther in the intestine. Many clients cannot tolerate the prone position. The lithotomy position is impractical for the procedure, and knee chest is too uncomfortable.

Which ostomy location would most likely need to be irrigated? Refer to figure.

1. A 2.B 3.C 4.D 4 The ostomy located at the juncture of the descending and sigmoid colon would be most likely to need irrigating because the effluent would be the most solid. Effluent in the ascending colon would be mostly liquid, and would become more solid as fluid is absorbed during passage through the transverse colon.

A licensed practical nurse (LPN) is assisting in the insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by performing which measurement?

1. A 30-inch length on the tube 2. An 18-inch length on the tube 3. From the tip of the client's nose to the earlobe and then down to the xiphoid process 4. From the tip of the client's nose to the earlobe and then down to the top of the sternum 3 The correct method for measuring the length of tube is to place the tube at the tip of the client's nose and measure by extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches.

The nurse is reviewing the risk factors for Clostridium difficile (C. difficile) infection with a student nurse. The nurse would determine there is a need for further teaching if the student nurse identifies which clients as being at risk for developing a C. difficile infection? Select all that apply.

1. A client receiving enteral nutrition 2. A client with coronary artery disease 3. A client receiving total parenteral nutrition 4. A client with human immunodeficiency virus (HIV) 5. A client taking pantoprazole for gastroesophageal reflux disease 6. A client taking antibiotics to treat frequent urinary tract infections 1,4,5,6 Certain factors increase the likelihood of contracting Clostridium difficile. Enteral nutrition bypasses the stomach acid's protective mechanism that kills pathogens. A client with HIV is more at risk for opportunistic infections due to the client's weakened immune system. Proton pump inhibitors (PPIs) such as pantoprazole decrease the acidity of stomach acid, which can allow pathogens to bypass this protective mechanism. Antibiotics kill the normal gastrointestinal (GI) flora that protect the GI tract from opportunistic infections. Therefore, options 1, 4, 5 and 6 are risk factors, whereas options 2 and 3 are not.

The nurse is talking to a nursing student about primary versus secondary peritonitis. The nurse determines that the student understands if the nursing student states which client is at risk for primary peritonitis?

1. A client with a ruptured appendix 2. A client receiving peritoneal dialysis 3. A client with ascites related to cirrhosis 4. A client with diverticulitis with rupture 3 Primary peritonitis usually occurs in the client with a disorder associated with underlying ascites. The client with cirrhosis with ascites is at risk for primary peritonitis. Secondary peritonitis is more common and occurs when another condition is the cause. Examples of secondary peritonitis include ruptured appendix, diverticulitis with rupture, severe cholecystitis, receiving peritoneal dialysis treatment, or trauma from knife or gunshot wounds

A primary health care provider asks the nurse to obtain a Salem sump tube for gastric intubation. The nurse would correctly select which tube from the unit storage area?

1. A feeding tube 2. A jejunostomy tube 3. A Sengstaken-Blakemore tube 4. A tube with a larger lumen and an air vent 4 A Salem sump tube is used commonly for gastric intubation and has a larger suction lumen and an air vent. A feeding tube describes a Levin tube. A jejunostomy tube describes a tube used for small intestinal feedings. A Sengstaken-Blakemore tube describes a tube used for gastroesophageal bleeding.

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse would most appropriately suggest which diet during the acute phase?

1. A low-fat diet 2. A high-fat diet 3. A low-fiber diet 4. A high-carbohydrate diet 3 A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is usually prescribed during the acute phase for acute diverticulitis, ulcerative colitis, and irritable bowel syndrome. Once the acute phase has subsided, the primary health care provider usually prescribes a high fiber diet. Neither a low-fat diet, a high-fat diet, nor a high-carbohydrate diet will aid in symptom management in acute diverticulitis.

A client diagnosed with peptic ulcer disease and scheduled for a pyloroplasty asks the nurse about the procedure. The nurse would base the response on which information?

1. A pyloroplasty involves cutting the vagus nerve. 2. A pyloroplasty involves removing the distal portion of the stomach. 3. A pyloroplasty involves removal of the ulcer and a large portion of the cells that produce hydrochloric acid. 4. A pyloroplasty involves an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. 4 Option 4 describes the procedure for a pyloroplasty. A vagotomy involves cutting the vagus nerve. A subtotal gastrectomy involves removing the distal portion of the stomach. A Billroth II procedure involves removal of the ulcer and a large portion of the cells that produce hydrochloric acid.

The client is taking docusate sodium. The nurse would monitor which result to determine if the client is having a therapeutic effect from this medication?

1. Abdominal pain 2. Reduction in steatorrhea 3. Hematest-negative stools 4. Regular bowel movements 4 Docusate sodium is a stool softener that promotes the absorption of water into the stool, producing a softer consistency of stool. The intended effect is relief or prevention of constipation. The medication does not relieve abdominal pain, stop gastrointestinal (GI) bleeding, or decrease the amount of fat in the stools.

The nurse is reinforcing dietary instructions for a client diagnosed with peptic ulcer disease. Which action would the nurse encourage the client to do?

1. Adhere to a strict soft, bland diet. 2. Eat only 6 small meals every day. 3. Eat anything as long as it does not aggravate or cause pain. 4. Include only foods that will increase gastrointestinal (GI) motility. 2 The client may eat foods as long as they do not aggravate or cause pain. Increased GI motility should be avoided. A traditional bland diet is no longer recommended. It is unnecessary for the client to eat 6 small meals per day with this disorder, although smaller meals are better managed by the client.

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed? Select all that apply.

1. Administer antacids, as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics, as prescribed. 4. Maintain the client in a supine and flat position. 5. Encourage small, frequent, high-calorie feedings. 1,2,3 The client with acute pancreatitis is normally placed on a nothing-by-mouth (NPO) status to rest the pancreas and suppress GI secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may also help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded, abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates and is unable to obtain any residual tube feeding. Which action would the nurse take next?

1. Administer the tube feeding slowly. 2. Contact the primary health care provider. 3. Turn the client to the side and attempt to aspirate again. 4. Auscultate bowel sounds and check for abdominal tenderness. 3 The nurse aspirates before administering an intermittent tube feeding to determine how well the formula is being absorbed. All of the tube feeding may have been absorbed, but the end of the tube may be up against the stomach wall. In this case the nurse has the client turn to move the tube and attempts to aspirate again to check for residual. Depending on the type of tube (such as a gastrostomy tube), the nurse may be able to safely administer the tube feeding without obtaining aspirated residual to note characteristics or pH to verify correct placement of the tube. The next action is not to notify the primary health care provider, administer the tube feeding slowly, or auscultate bowel sounds. These actions may be reasonable, but none of them is the next action of the nurse.

The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse would include which risk factor for colorectal cancer in the material?

1. Age of 20 years 2. High-fiber, low-fat diet 3. Distant relative with colorectal cancer 4. Personal history of ulcerative colitis or gastrointestinal (GI) polyps 4 Common risk factors for colorectal cancer include age over 40 years; first-degree relative with colorectal cancer; high-fat, low-fiber diet; and history of bowel problems such as ulcerative colitis or familial polyposis.

The nurse is reviewing a client's laboratory studies. Which laboratory studies support that the client is experiencing malnutrition? Select all that apply.

1. Albumin 4.6 g/dL (46 g/L) 2. Hemoglobin 8.6 g/dL (86 mmol/L) 3. Serum potassium 4.2 mEq/L (4.2 mmol/L) 4. Serum magnesium 1.3 mEq/L (0.53 mmol/L) 5. Alanine aminotransferase (ALT) 57 U/L (57 U/L) 2,4,5 Laboratory studies that support the diagnosis of malnutrition include decreased hemoglobin and hematocrit, hyperkalemia including other altered electrolyte levels, elevated liver enzymes, decreased albumin and prealbumin, decreased magnesium level, and decreased serum vitamin levels. Normal hemoglobin levels are 14-18 g/dL (140-180 mmol/L) for males and 12-16 g/dL (120-160 mmol/L) for females; therefore, a hemoglobin level of 8.6 g/dL is low and indicates malnutrition. A normal serum magnesium level ranges from 1.8-2.6 mEq/L (0.74-1.07 mmol/L); therefore, a serum magnesium level of 1.3 mEq/L is low and is indicative of malnutrition. ALT is reflective of liver function, and a normal level ranges from 4-36 U/L (4-36 U/L). Therefore, an ALT level of 57 is elevated and indicates malnutrition. A normal albumin level is 3.5-5.0 g/dL (35-50 g/L); therefore, a result of 4.6 g/dL is normal and does not indicate malnutrition. A normal potassium level is 3.5-5.0 mEq/L (3.5-5.0 mmol/L); therefore, a result of 4.2 mEq/L does not indicate malnutrition, as potassium levels are typically elevated in the presence of malnutrition.

The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure would the nurse include during client teaching to help prevent dumping syndrome?

1. Ambulate after a meal. 2. Eat high-carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high-Fowler's position during meals. 3 The client should be instructed to decrease the amount of fluid taken at meals. The client should also be instructed to avoid high-carbohydrate foods, including fluids such as fruit nectars; assume a low-Fowler's position during meals; lie down for 30 minutes after eating to delay gastric emptying; and take antispasmodics as prescribed.

The nurse working in an outpatient clinic is assisting with the admission intake on a client. The nurse asks about the reason for the visit, and the client describes a dull abdominal pain with diminished appetite and nausea. On further assessment, the pain is described as right sided and low, persistent, and continuous; the abdomen is tender, rigid with guarding and rebound tenderness. Based on the assessment findings, the nurse anticipates which diagnostic tests to be prescribed?

1. Amylase and lipase levels 2. Red blood cell count with indices 3. White blood cell count with differential 4. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) 3 The client's clinical presentation is consistent with acute appendicitis. The diagnostic tests used to confirm this diagnosis include the white blood cell count with differential, which often shows a moderately high white blood cell count. A urinalysis is often also conducted as well as a computed tomography (CT) scan to aid in confirmation. Amylase and lipase levels are used to diagnosis pancreatitis. Red blood cell counts with indices test for anemia. AST and ALT levels are used to confirm impairment in liver function.

The nurse is caring for a client diagnosed with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times?

1. An obturator 2. A Kelly clamp 3. An irrigation set 4. A pair of scissors 4 When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory distress that occurs if the gastric balloon ruptures moving the entire tube upward. If this occurs, all balloon lumens are cut and the tube is removed. An obturator and a Kelly clamp would be kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item.

A diagnosed with chronic gastritis has been told that there is too little intrinsic factor being produced. The nurse would explain to the client that which therapy will be prescribed to treat the problem?

1. Antacid use 2. Antibiotic therapy 3. Vitamin B6 injections 4. Vitamin B12 injections 4 Insufficient intrinsic factor results in the inability to absorb vitamin B12, which must then be supplemented by the parenteral route. Vitamin B6 is absorbed when given orally. Vitamin B6, antibiotic therapy, and antacid use do not help treat the lack of intrinsic factor.

A client has had a partial gastrectomy, and the nurse is reinforcing discharge instructions. The nurse would reinforce instructions to the client about the need for which supplements? Select all that apply.

1. Antacid use 2. Iron supplements 3. Antibiotic therapy 4. Calcium supplements 5. Vitamin B12 injections 2,4,5 Gastric surgery can have serious effects on the client's nutritional status. The absorption of vitamin B12, folic acid, iron, calcium, and vitamin D may be impaired, so supplements will be needed. Insufficient intrinsic factor results in the inability to absorb vitamin B12, which must then be supplemented by the parenteral route. Antibiotic therapy and antacid use would not help treat the lack of intrinsic factor or absorption of vitamins.

The nurse is assisting in caring for a client with a large penetrating wound to the abdomen and several smaller wounds containing shrapnel. The nurse plans for which appropriate nursing interventions? Select all that apply.

1. Apply pressure to bleeding wounds 2. Obtain blood for a type and crossmatch 3. Apply supplemental oxygen as ordered 4. Establish intravenous access with 2 large-bore catheters 5. Remove the impaled object and apply a pressure dressing 1,2,3,4 The appropriate nursing interventions for a client with a large penetrating abdominal wound and several smaller wounds containing foreign material would include applying pressure to control external bleeding, obtaining blood for laboratory studies including a type and crossmatch in the event a blood transfusion is needed, applying supplemental oxygen as prescribed, and establishing intravenous access to replace lost fluids. The nurse would never remove an impaled object, as this could cause further damage to the abdominal organs and also compromise the client's vascular status as this could cause the client to hemorrhage. The appropriate nursing intervention would be to cover the protruding object with a large bulky dressing. Removal of the penetrating object would most likely be done by a surgeon.

A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures will most likely promote coping? Select all that apply.

1. Ask a member of the local ostomy club to visit with the client before discharge. 2. Ask the enterostomal nurse specialist to consult with the client before discharge. 3. Remind the client frequently that infection is a major complication of a colostomy. 4. Remind the client frequently that he will be responsible for caring for the colostomy at home. 5. Ask the client to begin doing one part of the ostomy care each day and increase tasks daily. 1,2,5 A member of the local ostomy club will be able to provide realistic encouragement. The enterostomal nurse specialist will be able to provide helpful information to the client. Asking the client to assist with tasks may encourage the client to take on more advanced skills and become more adjusted to the ostomy. Reminding the client about the responsibility for caring for the colostomy and telling the client that infection is a major complication (which is incorrect) will alarm the client.

The nurse notes that the medical record of a client diagnosed with cirrhosis states that the client has asterixis. To effectively verify this information the nurse would take which action?

1. Ask the client to extend the arms. 2. Instruct the client to lean forward. 3. Ask the client to dorsiflex the calf. 4. Measure the client's abdominal girth. 1 Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. It is the most common and reliable sign that hepatic encephalopathy is developing.

The nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer would avoid which intervention?

1. Assessing for bowel sounds 2. Irrigating the nasogastric (NG) tube 3. Measuring the drainage from the nasogastric (NG) tube 4. Keeping the nasogastric (NG) tube connected to suction 2 After gastric surgery the nasogastric tube should not be irrigated. To do so may cause the suture line in the stomach to tear. Bowel sounds should be assessed, the drainage from the NG tube should be measured, and the tube should be kept to suction to be sure the stomach does not become distended.

A client with viral hepatitis states to the nurse, "I am so yellow." The nurse would best respond by taking which action?

1. Assist the client in expressing feelings. 2. Restrict visitors until the jaundice subsides. 3. Keep the client isolated from other clients and visitors. 4. Instruct the client that skin turning yellow is the consequence of alcoholism. 1 The client's feelings should be explored to discover how the client feels about the disease process and appearance so appropriate interventions can be planned. Restricting visitors, keeping the client isolated, and instructing the client that skin turning yellow is the consequence of alcoholism are inappropriate.

The nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse explains to the client that it is important to continue to do which action after discharge?

1. Avoid coughing. 2. Irrigate the drain. 3. Maintain bed rest. 4. Restrict pain medication. 1 Coughing is avoided to prevent disruption of the sutured tissue, which could occur because of the location of this surgical procedure; however, frequent deep breathing exercises are important. A drain is not placed in this procedure, although the client may be instructed in simple dressing changes. The client should continue to take analgesics as needed and as prescribed. Bed rest is not required following this surgical procedure.

The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse would include which instruction to the client?

1. Avoid iron supplementation. 2. Eat a diet high in vitamin B12. 3. Take actions to prevent dumping syndrome. 4. Self-monitor for signs and symptoms of lower gastrointestinal hemorrhage. 3 Dumping syndrome can occur in clients after gastric surgery and may occur as an early or late complication. Upper rather than lower gastrointestinal hemorrhage may also occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks intrinsic factor needed for absorption of the vitamin. Instead the client requires injections to supplement this vitamin. Iron supplements are necessary to help the absorption of parenteral vitamin B12.

A nurse organizing care for a client diagnosed with hepatitis plans to meet the client's safety needs by performing which action?

1. Bathing the client with tepid water and mild soap only 2. Assessing and recording the client's weight twice daily 3. Monitoring red blood cell and white blood cell counts daily 4. Monitoring prothrombin and partial thromboplastin values 4 When liver function is impaired, as in the client with hepatitis, some important body functions do not occur. The liver synthesizes fibrinogen, prothrombin, and factors needed for normal blood clotting. Without those clotting ingredients, bleeding may occur either internally or externally. Monitoring coagulation studies provides the nurse with information needed to plan ways to reduce the risk of hemorrhage when providing care. Daily weight is often part of a nursing care plan but is more related to fluid balance than safety; monitoring weight twice daily would not be necessary. Tepid baths may decrease the pruritus associated with jaundice, but this is not a safety issue either.

The nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement is most appropriate to be included in the teaching?

1. Be sure to sleep with your bed flat. 2. Avoid lying down for an hour after eating. 3 This problem is best resolved with a surgical procedure. 4. Eat foods that are higher in fat in order to slow down digestion." 2 Most clients with a hiatal hernia can be managed by conservative measures, which include a low-fat diet, avoiding lying down for an hour after eating, and raising the head of the bed.

The nurse is evaluating the effect of dietary counseling on the client diagnosed with cholecystitis. The nurse determines the client understands the instructions given if the client states that which food item is most appropriate to include in the diet?

1. Beef chili 2. Grilled steak 3. Mashed potatoes 4. Turkey and lettuce sandwich 4 The client with cholecystitis should decrease overall intake of dietary fat. Red meats (hamburger and steak) contain fat. Mashed potatoes are usually made with milk and butter. The correct food item that is low in fat is the turkey and lettuce sandwich.

Atropine sulfate is prescribed for the client diagnosed with gastrointestinal hypermotility, and the nurse reviews the client's record before administering the medication. Which finding, if noted on the client's record, most indicates the need to contact the primary health care provider before administering the medication?

1. Biliary colic 2. Sinus bradycardia 3. Narrow-angle glaucoma 4. History of peptic ulcer disease 3 Atropine sulfate can cause mydriasis (dilation of the pupil) and cycloplegia (relaxation of the ciliary muscles). It is contraindicated in clients with narrow-angle glaucoma. Options 1, 2, and 4 are all therapeutic reasons for using the medication.

A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which data finding best indicates adequate location of the tube?

1. Bowel sounds are absent. 2. The aspirate from the tube has a pH of 7.45. 3. The aspirate from the tube has a pH of 6.5. 4. The tube can be palpated to the right of the umbilicus. 2 The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine (to correct a bowel obstruction). The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is 7 or higher if the tube is adequately located. Location of the tube can also be determined by x-ray, not palpation. Options 1 and 3 are incorrect and would not determine adequate location of the tube.

A postoperative client has regained bowel sounds and is ready to start a clear liquid diet. The nurse is told that the primary health care provider has written a prescription to remove the nasogastric (NG) tube. The nurse assists in the procedure and would ask the client to do which during tube removal?

1. Breathe normally. 2. Exhale until the tube is out. 3. Perform the Valsalva maneuver. 4. Take a breath and hold it until the tube is out. 4 When the nurse removes an NG tube, the client is instructed to take a breath and hold it until the tube is out. This will close the epiglottis and prevent aspiration of any secretions. The nurse removes the tube with one very smooth continuous pull. The client is not asked to inhale or exhale to avoid aspirating any fluid left at the tip of the tube. It is unnecessary to perform the Valsalva maneuver.

The nurse is asked to assist with preparing a client who will be receiving a continuous total parenteral nutrition (TPN) solution via a central line. The nurse plans to institute which interventions for this client related to the TPN? Select all that apply.

1. Central line dressing changes per protocol 2. Blood glucose monitoring around the clock 3. Monitoring central venous pressure every shift 4. Using an electronic infusion pump with the infusion 5. Applying sequential compression devices (SCD) to the legs 6. Reviewing prescribed blood laboratory values including electrolytes 1, 2,4,6 The client receiving TPN is at an increased risk for fluid and electrolyte imbalance, hyperglycemia, and infection. The central line dressing is changed according to protocols set up to prevent infection. The TPN rate of infusion needs to be closely regulated with use of an electron infusion pump. The TPN contains increased concentration of glucose, so the blood glucose levels are monitored around the clock. Blood laboratory values are monitored often (3 times per week) because the electrolyte balance is totally dependent on the prescribed TPN solution. The TPN formula is adjusted and prescribed according to the client's laboratory results. Administration of TPN does not involve monitoring central venous pressure although that is possible through a central intravenous line. The client will be able to ambulate and so SCD are not required but may be prescribed for other reasons.

Which information would the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.

1. Change the appliance daily. 2. Empty pouch when 1⁄3 to 1⁄2 full.. 3. The stoma should be a dry pale pink. 4. The stoma should be moist and pink to red. 5. The skin barrier should be within 1⁄16 to 1⁄8 inch of the stoma. 6. Change the appliance about every 3 days, or sooner, if it is leaking effluent. 2,3,5 The pouch should be emptied when 1⁄3 to 1⁄2 full to prevent the weight of contents from loosening the seal. The stoma should be moist and pink to red in color. Keeping the skin barrier to within 1⁄16 to 1⁄8 inch of the base of the stoma prevents effluent from irritating the skin. With an adequate seal, changing the appliance every 3 days is adequate and may be done as infrequently as 2 weeks. Changing the appliance daily would damage the skin around the stoma. A dry pale pink is indicative of an unhealthy stoma and possibly dehydration.

The nurse is reviewing the medical record for a client with peritonitis. Which prescription would prompt the nurse to contact the registered nurse to seek clarification from the gastroenterologist?

1. Clear liquid diet 2. Strict intake and output 3. Intravenous antibiotics 4. Nasogastric tube insertion 1 Clients with peritonitis are normally placed on NPO (nothing-by-mouth) status. The nurse would clarify the clear liquid diet prescription. Monitoring strict intake and output, the administration of intravenous antibiotics, and nasogastric tube insertion are correct interventions used to treat a client with peritonitis.

A client that is postgastrectomy is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse would plan to monitor which data?

1. Client's daily weights 2. Fasting blood glucose readings 3. Postprandial blood glucose readings 4. Calorie counts from the dietary department 3 Late symptoms of dumping syndrome following a gastrectomy occur 2 to 3 hours after eating and result from a rapid entry of increased carbohydrate food into the jejunum, a rise in blood glucose levels, and excessive insulin secretion. To monitor this, the nurse checks the blood glucose level 2 hours after meals. Options 1 and 4 are unrelated to the data in the question. A fasting blood glucose level would not accurately determine hyperglycemia.

The nurse is providing education to a client regarding foods that can aggravate the symptoms of gastroesophageal reflux disease (GERD). The nurse identifies a need for further teaching when the client states which foods are acceptable to consume? Select all that apply.

1. Coffee 2. Oatmeal 3. Chocolate 4. Apple juice 5. Fried chicken 1,2,5 Coffee and other caffeine-containing beverages, chocolate, and fried, fatty foods such as fried chicken can aggravate GERD symptoms by decreasing the lower esophageal sphincter (LES) pressure, which allows acidic stomach contents to travel upwards into the esophagus, causing esophageal irritation and inflammation. Oatmeal and apple juice are not known to aggravate GERD symptoms.

The nurse working in the emergency department is assisting with an initial assessment on a client who is complaining of severe upper abdominal pain that spreads throughout the abdomen and radiates to the back and shoulders. The client has tried taking antacids with no relief. On assessment the abdomen is rigid and bowel sounds are absent. Which data in the client's history would the nurse be most concerned about in connection with these assessment findings?

1. Colon cancer 2. Diverticulosis 3. Peptic ulcer disease 4. Chronic pancreatitis 3 Given the clinical presentation for this client, the nurse would be most concerned about a reported history of peptic ulcer disease, because a complication of this disease is bowel perforation from an ulcer. With the findings of severe upper abdominal pain spreading through the abdomen and radiating to the back and shoulders, unrelieved by antacids, and rigid abdomen with absent bowel sounds, the nurse would suspect an acute abdomen problem. Colon cancer, diverticulosis, and chronic pancreatitis are chronic conditions that have less of a risk of causing an acute abdomen condition when compared to peptic ulcer disease. In addition, colon cancer and diverticulitis are most likely to cause lower abdominal pain. Chronic pancreatitis is more likely to cause left sided mid-abdominal pain.

The nurse analyzes the results of laboratory studies performed on a client with diagnosed peptic ulcer disease (PUD). Which laboratory value would most indicate a complication associated with the disease?

1. Creatinine 1 mg/dL 2. Hemoglobin 10.2 g/dL 3. Platelet count of 400,000 mm3 4. White blood cell count of 5000 mm3 2 The most common complications of peptic ulcer disease are hemorrhage, perforation, pyloric obstruction, and intractable disease. A low hemoglobin and hematocrit level indicate bleeding. The normal hemoglobin range in females is 12 to 16 g/dL and in males is 14 to 18 g/dL. A white blood cell count is performed to indicate the presence of infection or inflammation. The normal white blood cell count is 5000 to 10,000 mm3. The normal platelet range is 150,000 to 400,000 mm3. The creatinine measures renal function. The normal value is 0.6 to 1.3 mg/dL.

The nurse is assessing a client who fell at home and is complaining of abdominal pain. The nurse notes ecchymosis on the client's flanks and documents this as which assessment finding?

1. Cullen's sign 2. Murphy's sign 3. Brudzinski's sign 4. Grey Turner's sign 4 Grey Turner's sign is ecchymosis present on the flanks and can be a sign of retroperitoneal hemorrhage. Cullen's sign is similar, except the ecchymosis is present around the umbilicus and can also indicate retroperitoneal hemorrhage. Murphy's sign is present in cholecystitis and is elicited by placing the hand on the client's right upper abdominal quadrant and asking the client to breathe deeply. If pain is present, Murphy's sign is positive. Brudzinski's sign is positive if the client's hips and knees flex when the neck is flexed and can be indicative of meningitis.

The nurse reviewing a client's medical record would recognize which conditions as risk factors for nonalcoholic fatty liver disease (NAFLD)? Select all that apply.

1. Cystitis 2. Obesity 3. Diabetes 4. Hypotension 5. Pyelonephritis 6. Hyperlipidemia 2,3,6 The risk factors for nonalcoholic fatty liver disease (NAFLD) include obesity, diabetes, hypertension, and hyperlipidemia. These risk factors can contribute to increased fatty infiltrates being deposited in the liver. Cystitis and pyelonephritis are not associated with an increased risk of NAFLD.

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation would indicate that a prolapse has occurred?

1. Dark and bluish 2. Sunken and hidden 3. Narrowed and flattened 4. Protruding and swollen 4 A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed.

The nurse is collecting assessment data on an assigned client. Which assessment findings support that the client is experiencing dehydration? Select all that apply.

1. Dark urine 2. Cracked lips 3. Elastic skin turgor 4. Urine output of 20 ml in the past hour 5. Respiratory rate of 13 breaths per minute 1,2,4 Assessment findings that support dehydration include dark, concentrated urine, cracked and dry lips, decreased skin turgor in which the skin tents, a low urine output less than 30 mL per hour, and increased respiratory rate. Therefore, elastic skin turgor and a respiratory rate of 13 breaths per minute, which is within normal limits, is not indicative of dehydration.

The nurse is reviewing a chart of a client with irritable bowel syndrome (IBS) that is taking linaclotide. Which item documented in the client's history would prompt the nurse to consult with the registered nurse?

1. Diabetes 2. Hyperlipidemia 3. Coronary artery disease 4. Partial bowel obstruction 4 Linaclotide is used to treat and prevent diarrhea associated with irritable bowel syndrome (IBS). Linaclotide is contraindicated in clients with a history of mechanical bowel obstruction or previous bowel surgery. Therefore, the nurse would consult with the registered nurse if this item was noted in the client's history. The registered nurse would then contact the primary health care provider and question the prescription. Diabetes, hyperlipidemia, and coronary artery disease are not contraindications to this medication.

The nurse gathers data from a client admitted to the hospital with a diagnosis of gastroesophageal reflux disease (GERD) scheduled for a Nissen fundoplication. Based on an understanding of this disease, the nurse would determine that the client may be most at risk for which complication?

1. Diarrhea 2. Belching 3. Aspiration 4. Abdominal pain 3 The primary symptom of GERD is heartburn, which is also called pyrosis. Another symptom is regurgitation. The client reports the feeling of warm fluid traveling up the throat. If the fluid reaches the level of the pharynx the client notes a sour or bitter taste in the mouth. This effortless regurgitation frequently occurs when the client is in the upright position. If regurgitation occurs when the client is recumbent, the client is at risk for aspiration. Belching may be a symptom of the disease. Diarrhea and abdominal pain are not specifically associated with the disease.

The nurse is collecting admission data on the client with a diagnosis of hepatitis. Which finding would the nurse recognize to be a direct result of this client's condition?

1. Diarrhea 2. Drowsiness 3. Blurred vision 4. Urinary frequency 4 Hepatitis impairs liver function. If the liver is unable to perform its metabolic and detoxification functions, waste products begin to accumulate in the body. Many of those wastes are protein by-products, especially ammonia, which are harmful to the central nervous system. An increased ammonia level is the primary cause of the neurological changes seen in liver disease, beginning with drowsiness. The remaining options are not directly related to hepatitis

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic would the nurse expect to see documented in the record?

1. Diarrhea 2. Constipation 3. Bloody stools 4. Stool constantly oozing from the rectum 1 Crohn's disease is characterized by nonbloody diarrhea of usually not more than four or five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease.

The nurse is reviewing the medication record of a client with a diagnosis of acute gastritis. Which medication noted on the client's record would the nurse most likely question?

1. Digoxin 2. Ibuprofen 3. Furosemide 4. Propranolol hydrochloride 2 Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and can cause ulceration of the esophagus, stomach, duodenum, or small intestine. It is contraindicated in a client with a gastrointestinal disorder. Furosemide is a loop diuretic. Digoxin is an antidysrhythmic. Propranolol hydrochloride is a beta-adrenergic blocker. Furosemide, digoxin, and propranolol hydrochloride are not contraindicated in clients with gastric disorders.

The nurse is assisting with admitting a client to the hospital for the treatment of diagnosed dehydration. The client reports nausea, vomiting, diarrhea, and cramping for the past week. The nurse asks the client about medications being taken. The client denies taking prescription medications but states he has been taking some herbs given to him by a cousin. The nurse would alert the registered nurse when the client states he has been taking which herb?

1. Dill 2. Senna 3. Kaolin 4. Green tea 4 Senna is used to treat constipation and as a bowel preparation for surgery. Its side effects are nausea, vomiting, diarrhea, anorexia, and cramping. Side effects of kaolin are nausea, anorexia, and constipation. Common gastrointestinal (GI) side effects of green tea are nausea and heartburn; there are no known GI side effects from dill.

A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse would gather further information about the presence of which sign or symptom?

1. Dizziness after meals 2. Difficulty swallowing 3. Left lower quadrant pain 2 hours after eating 4. Moderate right upper quadrant pain unrelated to eating 2 Although many clients with hiatal hernia are asymptomatic those with symptoms usually have difficulty swallowing, along with heartburn and reflux. Dizziness after meals, left lower quadrant pain 2 hours after eating, and moderate right upper quadrant pain unrelated to eating are unrelated to this disorder.

A client calls the clinic and asks the nurse about measures to minimize pain and swelling for hemorrhoids. What is the correct response by the nurse?

1. Docusate sodium as directed twice a day 2. Sitz baths for 15 to 20 minutes 2 to 3 times a day 3. Ibuprofen as directed every 4-6 hours until resolved 4. Cool packs applied to the area while lying on the side in bed 2 Sitz baths for 15 to 20 minutes 2 to 3 times a day are helpful in managing the pain and swelling associated with hemorrhoids. Docusate sodium is helpful in softening the stool to aid in preventing constipation, but does not help the pain and swelling associated with hemorrhoids. Ibuprofen is an anti-inflammatory medication and works systemically, but is not specifically indicated for hemorrhoid management; the action of the local pain treatment using a sitz bath is more effective. Cool packs applied to the area while lying on the side in bed is not the recommended treatment for hemorrhoids and may cause injury to the affected area.

A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom associated with a hiatal hernia would the nurse recognize?

1. Dry cough 2. Left lower quadrant pain 3. Heartburn and regurgitation 4. Moderate right upper quadrant pain 3 Although many clients with a hiatal hernia are asymptomatic, those with symptoms usually have difficulty swallowing along with heartburn and reflux. Dry cough, left lower quadrant pain, and moderate right upper quadrant pain are not related to this disorder.

A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse would schedule the medication so that each dose is taken at which time?

1. During meals 2. 60 minutes after meals 3. 30 minutes before meals 4. On arising and at bedtime 3 To be effective in decreasing bowel motility, antispasmodic medications should be administered 30 minutes before mealtime. The other options are incorrect.

A primary health care provider asks the licensed practical nurse (LPN) to reinforce preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN would include which instruction in this discussion?

1. Eat a regular supper and breakfast. 2. Remove all metal and jewelry before the test. 3. Continue to take all oral medications as scheduled. 4. Expect diarrhea for a few days after the procedure. 2 A barium swallow, or esophagography, is an x-ray that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove all jewelry before the test, so it won't interfere with x-ray visualization of the field. The client should fast for 8 to 12 hours before the test, depending on primary health care provider instructions. Most oral medications also are withheld before the test. The client should self-monitor for constipation after the procedure, which can occur from barium in the GI tract.

The nurse who is reinforcing instructions to a client who has had a gastric resection would include which considerations? Select all that apply.

1. Eat small frequent meals. 2. Avoid iron supplementation. 3. Take action to prevent dumping syndrome. 4. Self-monitor for signs of lower gastrointestinal (GI) bleeding. 5. Consume a diet that is relatively high in vitamin B12 content. 1,3 After a gastrectomy, small frequent meals are given until the stomach stretches enough to tolerate three regular meals a day. Dumping syndrome occurs in many clients after GI surgery and may occur as an early or late complication. Upper GI hemorrhage also may occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks the intrinsic factor needed for absorption. Instead the client requires injection to supplement this vitamin. Iron supplements are necessary to help absorption of parenteral vitamin B12.

A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which considerations concerning ongoing self-management would the nurse reinforce to the client? Select all that apply.

1. Eat smaller and more frequent meals. 2. Resume full activity almost immediately. 3. Drink fluids between meals, not with them. 4. Stress will do little to exacerbate gastrointestinal symptoms. 5. Follow-up visits with the primary health care provider will no longer be needed. 1,3 Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. Fluids should be taken between meals, not with them, to avoid dumping syndrome. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client requires ongoing medical supervision and evaluation.

The nurse would document that a client diagnosed with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action?

1. Eating low-fat or nonfat foods 2. Elevating the foot of the bed during sleep 3. Doing household chores immediately after eating 4. Sleeping with the head of the bed slightly down 1 The use of low-fat or nonfat foods is recommended to reduce gastric pressure and prevent sliding of the hernia through the cardiac sphincter. The client should also elevate the head of the bed during sleep and wait at least 1 hour after meals to perform chores.

The nurse is teaching the client with vitamin B12 deficiency about foods that are good sources of vitamin B12. The nurse identifies a need for further teaching if the client states which foods are good sources of vitamin B12? Select all that apply.

1. Eggs 2. Clams 3. Broccoli 4. Citrus fruits 5. Organ meats 6. Yogurt parfait 3,4 Foods that are high in vitamin B12 are typically animal products, such as meat, fish, and dairy products. Therefore, the options that include non-animal products such as fruits and vegetables are not substantial sources of vitamin B12, making the correct answer options 3 and 4, broccoli and citrus fruits.

A client is admitted from the emergency department with a diagnosis of bowel perforation. Which treatment strategies would the nurse anticipate based on this admitting diagnosis? Select all that apply.

1. Electrocardiogram monitoring 2. Broad-spectrum antibiotic therapy 3. Nasogastric tube for enteral feedings 4. Insertion of an indwelling urinary catheter 5. Blood transfusion with fresh frozen plasma 6. Fluid replacement with lactated Ringer's solution 1,2,4,5 Anticipated treatment strategies for the client with bowel perforation include electrocardiogram monitoring to assess for cardiac dysrhythmias; broad-spectrum antibiotic therapy to treat bacterial peritonitis; nasogastric tube to stop the spillage of gastric and duodenal contents into the peritoneal cavity and to provide gastric decompression; insertion of an indwelling urinary catheter to monitor hourly urine output to accurately assess renal function; and fluid replacement with lactated Ringer's solution and blood transfusion with packed red blood cells (not fresh frozen plasma) to restore circulating volume. The nasogastric tube is not used for feedings; the client would be on NPO status.

A client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. Which is the appropriate intervention for the nurse to implement?

1. Encourage ambulation to stimulate peristalsis. 2. Administer prescribed antidiarrheal medications. 3. Make the client NPO and put the tube feeding on hold. 4. Notify the primary health care provider (PHCP) of the client's signs and symptoms. 4 Clients receiving tube feedings can develop distention and diarrhea due to hyperosmolarity of the formula, malabsorption, or contamination. The nurse should notify the PHCP about the problems of the client not tolerating the tube feeding. Encouraging ambulation may improve peristalsis, but this will not improve toleration of the tube feeding. Administering antidiarrheal medication or stopping the tube feeding should not be done without approval of the PHCP. If the client was made NPO without the tube feeding, the client would be at risk for dehydration.

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings?

1. Enteral feedings are a frequent cause of sepsis. 2. Tube feedings should be refrigerated until just before use. 3. The caloric value of enteral feedings is generally 5 to 10 kcal/mL. 4. Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract. 4 Enteral nutrition can include providing nutrients by mouth, nasogastric tube, gastrostomy tubes, or a percutaneous endoscopic gastrostomy (PEG) tube. The common element in each of these methods of delivery is that the client must have normal GI digestive capabilities. If the client does not have a normal GI tract, other methods of nutrient delivery must be sought, such as parenteral nutrition. Enteral feedings may cause aspiration pneumonia because of regurgitation of formula into the lungs; however, they are not generally associated with sepsis. Tube feedings should be given at room temperature to avoid problems with diarrhea. The caloric value of most standard enteral feeding formulas is 1 to 2 kcal/mL.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. The nurse would plan care knowing that most likely, which problem will occur with this disorder?

1. Excess fluid volume related to sodium retention 2. Alteration in comfort related to abdominal pain 3. Alteration in fluid and electrolyte balance related to hyperkalemia 4. Potential for hypoglycemia related to a low blood glucose secondary to increased insulin secretion 2 Abdominal pain is the predominant symptom of acute pancreatitis. Shock and hypovolemia may occur from hemorrhage, toxemia, or loss of fluid into the peritoneal space. Potassium and sodium may be lost due to gastric suction and frequent vomiting. Hyperglycemia may result from impaired carbohydrate metabolism.

The nurse is caring for a client with dehydration. The nurse is aware that dehydration is associated with which imbalances?

1. Extracellular fluid volume deficit and hypernatremia 2. Extracellular fluid volume excess and hyponatremia 3. Extracellular fluid volume deficit and normal osmolality 4. Extracellular fluid volume excess and normal osmolality 1 Dehydration is defined as extracellular fluid volume deficit occurring concurrently with hypernatremia, therefore body fluids have decreased volume and increased concentration as the body loses water without losing sodium. Extracellular fluid volume excess and hyponatremia, otherwise known as water intoxication, occurs when there is an excess of body fluid, which dilutes the concentration of sodium. Extracellular fluid volume deficit with normal osmolality occurs when water and sodium is lost at the same rate, causing an isotonic loss. Extracellular fluid volume excess with a normal osmolality occurs when sodium and water intake is greater than output, causing an isotonic gain.

A client is admitted to the hospital with a diagnosis of acute viral hepatitis. Which sign/symptom would the nurse expect to observe based on this diagnosis?

1. Fatigue 2. Pale urine 3. Weight gain 4. Spider angiomas 1 Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas—small, dilated blood vessels—are commonly seen in cirrhosis of the liver.

The nurse caring for a client with a diagnosis of cholelithiasis observes for signs of obstruction of the bile ducts. Which assessment findings are indicative of this complication? Select all that apply.

1. Fever 2. Jaundice 3. Dark, foamy urine 4. Clay-colored stools 5. Headache and diarrhea 6. Severe pain in the lower abdomen 1,3,4 Assessment for complications associated with cholelithiasis should be focused on observing for signs of obstruction of the ducts by gallstones. Signs of obstruction of the ducts include jaundice, clay-colored stools, dark, foamy urine, steatorrhea, fever, and increased white blood cell count. Headache and diarrhea and severe pain in the lower abdomen are not associated manifestations. The pain in gallbladder disease is right-sided and radiates to the back.

The nurse is assisting in caring for a client that has arrived to the post-anesthesia care unit following an esophagogastroduodenoscopy (EGD) to confirm diagnosis of esophageal stricture. Which findings are signs of esophageal perforation? Select all that apply.

1. Fever 2. Tachypnea 3. Bradycardia 4. Hypotension 5. Abdominal pain 1,2,4,5 An EGD is a procedure in which a flexible scope with a camera is passed through the mouth and down the esophagus. EGD allows the primary health care provider to visualize the upper gastrointestinal tract to diagnose and treat several conditions, including esophageal stricture. Complications of an EGD include esophageal perforation, in which the esophagus sustains a tear. Signs of esophageal perforation include fever, increased respiratory rate (tachypnea), tachycardia (not bradycardia), hypotension, and pain that can be felt in the neck, shoulder, or upper or lower back (not the abdomen) that may increase when lying flat. Therefore, options 1, 2, and 4 are correct.

The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?

1. Fever and pruritic urticaria 2. Bradycardia and altered taste 3. Hypothermia and muscle weakness 4. Hypertension and decreased urine output 1 IV fat emulsions are sometimes administered with parenteral nutrition to supply needed calories and essential fatty acids. This fat emulsion must be infused by pump at a set rate, usually over 10 to 12 hours. Signs and symptoms of fat overload include fever, leukocytosis, hyperlipidemia, and pruritic urticaria, and focal seizures are possible. Hepatosplenomegaly also may be present. Bradycardia, altered taste, muscle weakness, hypertension, and decreased urine output are not signs of this complication.

A client with Crohns's disease has just had surgery to create an ileostomy. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery?

1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance 4 A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

The nurse is administering pantoprazole to a client with gastroesophageal reflux disease (GERD). The nurse understands that pantoprazole has which potential adverse effects? Select all that apply

1. Fractures 2. Pneumonia 3. Hypokalemia 4. Low hemoglobin 5. Hypomagnesemia 1,2,5 Pantoprazole belongs to the drug class called proton pump inhibitors (PPIs). Long-term PPI use is linked to osteoporosis, which weakens bones and increases the client's risk for fractures. PPIs are thought to alter the upper gastrointestinal flora and impair white blood cell function, increasing the risk of pneumonia. Additionally, long-term PPI use can lower serum magnesium levels due to poor intestinal absorption of magnesium, which can result in hypomagnesemia. Low hemoglobin and hypokalemia are not adverse effects of pantoprazole.

The nurse is providing dietary instructions to a client with a diagnosis of ulcerative colitis. The client is prescribed to follow a low residue diet during episodes of diarrhea. Which food would the nurse instruct the client to avoid?

1. Fresh corn on the cob 2. Broiled chicken breast 3. Gelatin with canned fruit 4. Bagels with cream cheese 1 Ulcerative colitis is a chronic inflammatory bowel disease in which the colon becomes edematous, develops ulcerated areas, and results in bloody diarrhea that occurs with exacerbations. A low-residue (low-fiber) diet is prescribed for some clients during exacerbations because this places less strain on the intestines and is easier to digest. The item that contains high residue and thus would place strain on the intestines is the fresh corn on the cob.

The nurse is providing care for a client suspected of having appendicitis. Which priority intervention would the nurse anticipate will be prescribed for this client?

1. Full liquid diet 2. Clear liquid diet 3. Mechanical soft diet 4. No oral intake of liquids or food 4 For a client with suspected or known appendicitis, the nurse should ensure the client remains on nothing by mouth status in anticipation of emergency surgery and also to avoid worsening the inflammation. Options 1, 2, and 3 are not prescribed for the client with suspected appendicitis.

The nurse is caring for a client following an esophagogastroduodenoscopy (EGD) done to confirm the diagnosis of esophageal stricture. Which assessment is priority after this procedure to promote client safety?

1. Gag reflex 2. Lung sounds 3. Bowel sounds 4. Peripheral pulses 1 An EGD is a procedure in which a flexible scope with a camera is passed through the mouth and down the esophagus. During the procedure, the client is placed under moderate sedation and a local anesthetic spray is administered orally to diminish the gag reflex. Therefore, option 1 is the correct answer. The priority assessment to promote client safety is to assess if the gag reflex is intact after the procedure prior to offering any food or fluids orally to prevent aspiration.

The nurse is caring for a client with a history of peptic ulcer disease admitted to the medical-surgical unit with abdominal pain that is worse towards the end of the day. The client tells the nurse that he has had a bowel perforation in the past that healed on its own. Given the client's history, which condition would the nurse suspect?

1. Gastric ulcer 2. Duodenal ulcer 3. Gastric outlet obstruction 4. Gastrointestinal hemorrhage 3 Gastric outlet obstruction is characterized by epigastric abdominal pain and postprandial vomiting due to mechanical obstruction. Acute and chronic peptic ulcer disease, which includes both gastric and duodenal ulcers, can cause gastric outlet obstruction. Particularly when small perforations caused by ulcers heal on their own, strictures and obstruction of intestinal contents and the passage of stool can occur from scar tissue formation. The client's history and clinical presentation depict gastric outlet obstruction. Recall that gastric and duodenal ulcers can cause gastrointestinal hemorrhage, and can eventually cause gastric outlet obstruction as a result of the healing process.

The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse would most likely suspect that the client has which diagnosis?

1. Gastritis 2. Bowel obstruction 3. Small bowel tumor 4. Esophageal varices 4 A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices when other measures used to treat the varices are unsuccessful or contraindicated for the client. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. This tube is not used to treat the conditions noted in the remaining options.

The nurse is collecting data during an assessment on a client. Which of the following assessment findings are typical for a malnourished client? Select all that apply.

1. Glossitis 2. Cheilosis 3. Bleeding gums 4. Digital clubbing 5. Pink conjunctivae 1,2,3 Malnourishment can cause many notable manifestations, including glossitis, which is a swollen, red, beefy tongue; cheilosis, which are crusts or lesions at the corners of the mouth; and bleeding gums. Digital clubbing is noted when a client has chronically low oxygen levels (hypoxia). Red or pale conjunctivae, not pink conjunctivae, are noted when a client is malnourished.

A client diagnosed with a peptic ulcer scheduled for a vagotomy asks the nurse about the purpose of this procedure. The nurse would explain to the client that a vagotomy primarily serves which purpose?

1. Halts stress reactions 2. Heals the gastric mucosa 3. Reduces the stimulation of acid secretions 4. Decreases food absorption in the stomach 3 A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Halting stress reactions, healing the gastric mucosa, and decreasing food absorption in the stomach are incorrect descriptions of a vagotomy.

The nurse is interpreting the laboratory results of a client who has a history of diagnosed chronic ulcerative colitis. The nurse would determine that which result indicates a complication of ulcerative colitis?

1. Hemoglobin 10.2 g/dL 2. Potassium 4.1 mEq/L 3. Prothrombin time 10.9 seconds 4. White blood cell count 6300 mm3 1 A normal hemoglobin level ranges from 12 to 16 g/dL. The client with ulcerative colitis is most likely anemic because of chronic blood loss in small amounts with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. The other laboratory results are within a normal range.

It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing?

1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D 1 HAV is transmitted by the fecal-oral route via contaminated food or infected food handlers. HBV, HCV, and HDV are most commonly transmitted via infected blood or body fluids.

Which infection control method would the nurse determine to be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure?

1. Hepatitis B vaccine 2. Proper personal hygiene 3. Use of immune globulin 4. Correct hand-washing technique 1 Immunization is the most effective method of preventing hepatitis B infection. Other general measures include hand washing. Immune globulin may be used to prevent hepatitis A and is used for prophylaxis if the client is traveling to endemic areas. Personal hygiene, such as hand washing after a bowel movement and before eating, also helps prevent the transmission of hepatitis A.

The nurse is caring for a client with a diagnosis of anal fistula. Which condition would the nurse most likely expect to note in the client's medical history?

1. Hernia 2. Hemorrhoids 3. Crohn's disease 4. Peptic ulcer disease 3 Anal fistulas are abnormal openings or tunneling leading from the anus or from the rectum. These fistulas are a complication associated with Crohn's disease and occur as a result of the inflammatory changes in Crohn's.

A client has a diagnosis of asymptomatic diverticular disease. Which type of diet would the nurse anticipate being prescribed?

1. High-iron diet 2. High-fiber diet 3. Low-purine diet 4. Low-sodium diet 2 A high-fiber diet is the diet of choice for asymptomatic diverticular disease to help prevent straining from constipation. A high-iron diet is for clients with anemia to help make hemoglobin. A low-purine diet is for clients with gout to prevent formation of stones and crystals. Hypertensive clients and clients with cardiac problems may require a low-sodium diet to prevent increased fluid volume.

The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history would the nurse determine is least likely associated with this disease?

1. History of alcohol abuse 2. History of tarry black stools 3. History of gastric pain 2 to 4 hours after meals 4. History of the use of acetaminophen for pain and discomfort 4 Unlike aspirin (acetylsalicylic acid), acetaminophen has little effect on platelet function, doesn't affect bleeding time, and generally produces no gastric bleeding. History of alcohol abuse, tarry black stools, and gastric pain 2 to 4 hours after meals, if reported by the client, are indications of peptic ulcer disease.

The client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse would gather which additional data from the client to support this diagnosis?

1. History of alcohol use, smoking, and weight loss 2. Frequent "heartburn" with a sour taste in the mouth 3. Complaints of stress with a history of chronic kidney disease 4 Blood group and history of chronic obstructive pulmonary disease with weight gain 1 Alcohol use, smoking, and weight loss are most commonly associated with gastric ulcers. The other options do not identify risk factors commonly associated with this disorder. Frequent "heartburn" with a sour taste in the mouth may be seen in gastroesophageal reflux disease.

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. The nurse would determine that which data would further support this diagnosis?

1. History of frequent intake of spicy foods 2. Frequent heartburn with a sour taste in the mouth 3. Complaints of stress with a history of chronic kidney disease 4. History of chronic obstructive pulmonary disease with weight loss 4 History of chronic obstructive pulmonary disease is commonly associated with gastric ulcers, because this disease increases gastric acid secretion. Weight loss is also associated with gastric ulcer disease. The other options do not contain risk factors or symptoms commonly associated with this disorder. The symptoms listed in option 2 may be seen in gastroesophageal reflux disease. Spicy foods often have been blamed for ulcers, but this link has not been proven.

The nurse is reinforcing teaching to a client diagnosed with an anal fissure. The nurse discusses the possible treatment measures for this problem. The nurse accurately identifies which measures during the teaching session? Select all that apply.

1. Hot tub use 2. Topical nitrates 3. Fiber supplements 4. Lateral sphincterotomy 5. Botulinum toxin injection 6. Topical calcium channel blockers 2,3,4,5,6 Treatment strategies for anal fissure are aimed at preventing constipation and using conservative measures to decrease anal and rectal pressure. Treatment strategies include warm sitz baths using lukewarm water (not hot tub use), topical nitrates and calcium channel blockers, fiber supplements to prevent constipation and increased fluid intake, botulinum toxin injection, and lateral sphincterotomy.

A client is admitted to an acute care facility with complications of celiac disease. Which question asked by the nurse initially would be most helpful in obtaining information for the nursing care plan?

1. How long have you been diagnosed?" 2. "What types of foods do you like to eat?" 3. "What is your understanding of celiac disease?" 4. "Have you eliminated whole wheat bread from your diet?" 3 Celiac disease is also known as "gluten-induced enteropathy." It causes diseased intestinal villi that result in decreased absorptive surfaces and malabsorption syndrome. Clients with celiac disease must maintain a gluten-free diet, which eliminates all products made from wheat, rye, oats, barley, buckwheat, or graham. Many products may contain gluten without the client's knowledge. Beer, pasta, crackers, cereals, and many more substances contain gluten. It is often very difficult for a client to learn all of the food substances that must be eliminated from a diet. Also it is often very difficult for a client to adhere to a strict diet. Therefore, initially it is important for the nurse to determine the client's understanding of the disease. The remaining options are appropriate questions but are not important initially.

A client with a diagnosis of acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic prescription on the primary health care provider prescription sheet, the nurse would suggest contacting the primary health care provider to request a prescription for which medication?

1. Hydromorphone 2. Morphine sulfate 3. Acetylsalicylic acid 4. Acetaminophen with codeine 1 Hydromorphone rather than morphine is the medication of choice because morphine can cause spasms in the sphincter of Oddi. Acetylsalicylic acid and acetaminophen with codeine are inappropriate medications because they are not potent enough and because they require the oral route. The client with acute pancreatitis should take nothing by mouth (NPO).

A client diagnosed with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is most likely a result of which condition that is part of the client's health history?

1. Hypothyroidism 2. Hemigastrectomy 3. Excessive vitamin C intake 4. Decreased dietary intake of iron 2 The client who has had surgical resection of the stomach or small intestine may develop pernicious anemia as a complication. This results from decreased production of intrinsic factor (gastrectomy) or decreased surface area for vitamin B12 absorption (intestinal resection). The client then requires vitamin B12 injections for life. Decreased iron intake leads to iron deficiency anemia, which is often easily treated with iron supplements. Excessive vitamin C intake and hypothyroidism are unrelated to pernicious anemia.

The nurse is reinforcing dietary instructions for a client diagnosed with peptic ulcer disease. Which statement made by the client indicates a need for further teaching?

1. I will eat a bland diet only. 2. I will be sure not to skip meals. 3. I will exclude coffee and tea from my diet. 4. If spicy foods cause pain, I will avoid them in my diet. 1 A bland diet is unnecessary. The client should not skip meals, but tea and coffee should be avoided because they cause an increase in acid production. Spicy foods should be discontinued if they cause pain.

The nurse caring for a client diagnosed with acute pancreatitis and has a history of alcoholism is monitoring the client for complications. The nurse determines that which data collected is most likely indicative of paralytic ileus?

1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margin 1 An inflammatory reaction, such as acute pancreatitis, can cause paralytic ileus the most common form of nonmechanical obstruction. Inability to pass flatus is a sign/symptom of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. A firm, nontender mass palpable at the lower right costal margin describes the physical finding of liver enlargement. The liver is usually enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, it is not a sign of paralytic ileus or intestinal obstruction.

An older client complains of chronic constipation. Which instructions would the nurse reinforce with the client? Select all that apply.

1. Include rice and bananas in the diet. 2. Increase the intake of sugar-free products. 3. Increase fluids to at least 8 glasses a day. 4. Increase various potassium-rich foods in the diet. 5. Respond in a timely manner to the urge to defecate. 3 Increase of fluid intake and dietary fiber will help change the consistency of the stool and make it easier for the client to pass. Clients should respond to the feeling of peristalsis involved with the urge to defecate. Some older clients with mobility issues may not respond to the urge. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not be beneficial to the client.

A client receiving iron supplements is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? Select all that apply.

1. Increase your fluid intake. 2. Include more fiber in your diet. 3. Ferrous sulfate changes the color of stool to black. 4. Iron slows colonic acid and often leads to constipation. 5. Use an enema every other day if you don't have a bowel movement. 6. Signs of constipation include not having a bowel movement every day. 1,2,3 As motility slows, feces are exposed to the intestinal walls and water is absorbed. Increasing fluid intake will help by adding more fluid to the intestinal contents. Fiber increases motility. Iron and several other medications slow motility. Lack of exercise or bed rest contributes to constipation. An enema should not be used every other day, usually no more frequently than on the third day. Many people do not have bowel movements every day. Constipation is not having a bowel movement in 3 days.

The nurse is reviewing a client's laboratory results. The nurse notes that which results support a diagnosis of dehydration? Select all that apply.

1. Increased creatinine 2. Increased hemoglobin 3. Increased serum sodium 4. Decreased urine specific gravity 5. Decreased estimated glomerular filtration rate (eGFR) 1,2,3,5 Laboratory results that support the diagnosis of dehydration include increased creatinine, increased hemoglobin, increased serum sodium, and decreased eGFR. As dehydration progresses, renal function is affected, causing creatinine to increase. eGFR is a measure of the rate at which the kidneys are filtering the blood, which decreases as dehydration progresses. When a client is severely dehydrated, plasma volume in blood decreases, causing an increase in hemoglobin due to hemo-concentration. Serum sodium increases, as dehydration is water loss without corresponding sodium loss. Increased urine specific gravity, not decreased, is indicative of dehydration.

The nurse is caring for a client diagnosed with anal fistula and is monitoring for complications of this problem. Which priority complication would the nurse monitor for while managing care for this client?

1. Infection 2. Dehydration 3. Skin impairment 4. Body image disturbance 1 An anal fistula causes tunneling in the anus or rectum. With a fistula, feces can enter the affected area, which can potentially lead to infection usually manifested as abscess formation. Dehydration may also be evident but is less likely because of the location of the fistula. Skin impairment is possible because of the leakage of stool, but it is not the highest priority. Body image disturbance may be evident because of staining clothing and the odor associated with this problem, but it is not the highest priority.

A primary health care provider places a Miller-Abbott tube in a client who has a diagnosed bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action would the nurse take next?

1. Initiate a tube feeding. 2. Notify the registered nurse. 3. Document the finding in the client's record. 4. Pull the tube out 6 cm, and secure the tube to the nose with tape. 2 The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine and correct a bowel obstruction. Initial insertion of the tube is a primary health care provider's responsibility. The tube is weighted by a special substance and either advances by gravity or may be advanced manually. Advancement of the tube can be monitored by measuring the tube and by taking serial x-rays. Initiating a tube feeding, notifying the registered nurse, and pulling the tube out 6 cm are incorrect nursing actions. The nurse would, however, keep the registered nurse informed about the progress of the tube advancement.

The client arrives at an emergency department complaining of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the primary health care provider's prescriptions. Which prescription would the nurse most likely question if written on the primary health care provider's prescription form?

1. Insertion of a nasogastric (NG) tube 2. Insertion of an intravenous (IV) line 3. Administration of an opioid analgesic 4. Maintaining a nothing-by-mouth (NPO) status 3 Until a differential diagnosis is determined and a decision about the need for surgery is made, the nurse should question a prescription to give an opioid analgesic because it could mask the client's symptoms. The nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of an NG tube may be helpful to provide decompression of the stomach.

An acutely ill-looking client arrives at the emergency department. The client complains of "the worst pain I ever felt in my belly. I can't get comfortable." The client is quiet but with each movement the client cries out in pain. The nurse suspects the client has peritonitis. Which data would the nurse collect to assist in validating this suspicion? Select all that apply.

1. Inspect the abdomen for rigidity. 2. Check for the presence of hiccups. 3. Check for the presence of bradycardia. 4. Auscultate the abdomen for borborygmi. 5. Inspect the client's mucous membranes. 1,2 The nurse would assess for hiccups because this is a sign of diaphragmatic irritation. Tachycardia, not bradycardia, and hypoactive or absent bowels sounds, not hyperactive bowel sounds, would be present in peritonitis. Abdominal rigidity is a classic sign of peritonitis, a potentially life-threatening acute inflammatory disorder. Mucous membranes will begin to be dry and become pale as fluid begins to third space.

The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which considerations would the nurse include in the teaching session? Select all that apply.

1. It is advisable to stop smoking cigarettes. 2. Lie flat for at least 30 minutes after meals. 3. Wait at least 1 hour after meals to perform chores. 4. Be sure to elevate the head of the bed during sleep. 5. Foods with moderate fat should be a part of your diet. 1,3,4 The client should elevate the head of the bed during sleep and wait at least 1 hour after meals to perform chores. Smoking cigarettes increases acid secretion, so the client should be advised to stop smoking. The consumption of low-fat or nonfat foods is recommended, not moderate fat. The client should remain upright for an hour after eating.

The nurse is reviewing a client's medications. The nurse determines which medications increase the client's risk of dehydration? Select all that apply.

1. Lactulose 2. Ondansetron 3. Pantoprazole 4. Spironolactone 5. Polyethylene glycol 1,4,5 Medications that put the client at risk for dehydration enhance fluid loss through various routes, such as through the urinary tract or gastrointestinal tract. Lactulose and polyethylene glycol are osmotic laxatives that draw water into the intestine to soften stool and stimulate a bowel movement, therefore excreting water through the stool, which can dehydrate if fluids are not replaced. Spironolactone is a potassium-sparing diuretic that promotes diuresis and increases the risk of dehydration. Ondansetron is an anti-emetic that is used to treat and prevent nausea and vomiting, which prevents dehydration. Pantoprazole is a proton pump inhibitor that blocks the production of hydrochloric acid in the stomach to treat several conditions such as gastroesophageal reflux disease (GERD). Pantoprazole is not associated with dehydration.

A client is admitted to the hospital with a diagnosed bowel obstruction secondary to a recurrent diagnosed malignancy. The primary health care provider plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, which action would the nurse determine is best?

1. Leave the room. 2. Remain with the client and be silent. 3. Ask the client whether he would like another nurse to care for him. 4.Explain to the client that all clients have the right to know about medical procedures. 2 The nurse needs to recognize that the client has a greater need for security and acceptance than education. In option 2, the nurse conveys acceptance of the client and uses the therapeutic communication technique of silence. Leaving the room, asking the client if he would like another nurse to care for him, and explaining to the client that all clients have the right to know about medical procedures block communication and do not address the client's need.

The nurse has assisted the primary health care provider with a liver biopsy, which was done at the bedside. Upon completion of the procedure, the nurse would assist the client into which position?

1. Left side-lying with the right arm elevated above the head 2. Right side-lying with the left arm elevated above the head 3. Left side-lying with a small pillow or towel under the puncture site 4. Right side-lying with a small pillow or towel under the puncture site 4 Following a liver biopsy the client is assisted to assume a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours. This helps immobilize the area and provides pressure to minimize bleeding in this vascular organ. The other options are incorrect.

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which would the nurse clarify?

1. Leg exercises 2 Early ambulation 3 Irrigating the nasogastric (NG) tube 4 Coughing and deep-breathing exercises 3 In a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse, however, should never irrigate or reposition the NG tube after gastric surgery unless specifically prescribed by the surgeon. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.

The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse determines to include which essential elements in the discharge teaching guide? Select all that apply.

1. Limit alcohol intake to one drink a day. 2. Avoid potentially hepatotoxic over-the-counter drugs. 3. Teach symptoms of complications and when to seek prompt medical attention. 4. Explain that cirrhosis of the liver is a chronic illness and the importance of continuous health care. 5. Avoid spicy and rough foods and activities that increase portal pressure such as straining at stool, coughing, sneezing and vomiting. 6. Avoid aspirin and non-steroidal anti-inflammatory drugs to prevent hemorrhage when esophageal varices are present and substitute with acetaminophen. 2,3,4,5 Because the liver is unable to metabolize many over-the-counter drugs it is important for the client to avoid these. The client and family must also know that cirrhosis of the liver is a chronic condition, and there are many associated complications that require immediate medical intervention. Because of the risk of hemorrhage, spicy food and activities that increase pressure within the portal system must be avoided.

The nurse is caring for a client with a neurogenic bowel due to a lower motor neuron spinal cord injury below T12 resulting in flaccid functionality. Besides triggering or facilitating techniques for defecation, what are some of the strategies the nurse needs to address to reestablish defecation patterns? Select all that apply.

1. Limit fluids 2. Low-fiber diet 3. Suppository use 4. Manual disimpaction 5. Consistent toileting schedule 6. Drinks with caffeine (coffee, tea, cocoa) and many soft drinks 3,4,5 Besides using triggering or facilitating techniques, the strategies the nurse needs to address that would help reestablish defecation patterns include a high-fiber, not low-fiber, diet; increased, not limited, fluids; suppository use; manual disimpaction; and a consistent toileting schedule. The client needs to avoid drinks with caffeine such as coffee, tea and cocoa, and many soft drinks.

The nurse is instructing a client who had a herniorrhaphy about how to reduce postoperative swelling following the procedure. Which would the nurse suggest to the client to prevent swelling?

1. Limit fluids. 2. Elevate the scrotum. 3. Apply heat to the abdomen. 4. Maintain a low-roughage diet. 2 Following herniorrhaphy, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The client also is instructed to apply a scrotal support when out of bed. Limiting fluids, applying heat to the abdomen, and maintaining a low-roughage diet are incorrect.

The nurse is caring for a client in the pre-operative period scheduled for a hemorrhoidectomy. The nurse would inform the surgeon about which medication, if noted in the client's home medication list?

1. Lisinopril 2. Clopidogrel 3. Atorvastatin 4. Amiodarone 2 Clopidogrel is an antiplatelet medication used to prevent cardiovascular events, which is associated with an increased risk of bleeding, especially during surgery. Lisinopril is an angiotensin-converting enzyme inhibitor that is used to manage hypertension and heart failure. A common adverse effect is hyperkalemia. Atorvastatin is an HMG-CoA reductase inhibitor, also known as a statin, which is used to manage hyperlipidemia. A common adverse effect is liver injury. Amiodarone is an antidysrhythmic medication used to manage heart rhythm problems. A common adverse effect is pulmonary toxicity.

The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription would the nurse most question?

1. Lorazepam 2. Furosemide 3. Omeprazole 4. Acetaminophen 4 Acetaminophen can cause hepatotoxicity, and its use is avoided in the client with liver disease. Furosemide and omeprazole do not adversely affect liver function. Lorazepam can cause liver damage in high doses or with long-term therapy but can still be used (with caution) in the client with liver disease.

The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression in a client with a bowel obstruction. Which settings would the nurse anticipate to be prescribed by the primary health care provider? Select all that apply.

1. Low 2. High 3. Medium 4. Continuous 5. Intermittent 1,5 A Levin tube has no air vent, and the suction must be placed on a low and intermittent setting to prevent trauma to the gastric mucosa. A Salem sump tube allows for continuous suction because of the presence of an air vent on that tube. Low suction pressure is safer for the stomach than high pressure.

The nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse would anticipate a prescription to set the suction to which pressure?

1. Low and continuous 2. High and intermittent 3. Low and intermittent 4. High and continuous 3 A Levin tube has no air vent, and the suction must be placed on an intermittent setting to prevent trauma to the gastric mucosa. Low pressure and intermittent suction are safer for the stomach than high pressure and continuous suction.

A client has been diagnosed with acute gastroenteritis. Which diet would the nurse anticipate to be prescribed for the client?

1. Low fat 2. Low fiber 3. High fiber 4. High carbohydrate 2 A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is prescribed for clients with inflammatory bowel disease, ileostomy, colostomy, partial obstructions of the intestinal tract, acute gastroenteritis, or diarrhea.

A client is resuming a diet after partial gastrectomy. To minimize complications, the nurse would instruct the client to avoid which behavior?

1. Lying down after eating 2. Drinking liquids with meals 3. Eating 6 small meals per day 4. Excluding concentrated sweets in the diet 2 The client who has had a hemigastrectomy is at risk for dumping syndrome. This client should be placed on a diet that is high in protein, moderate in fat, and high in calories. The client should avoid drinking liquids with meals. Frequent small meals are encouraged, and the client should avoid concentrated sweets.

A client with hiatal hernia chronically experiences heartburn after meals. Which would the nurse teach the client to avoid?

1. Lying recumbent after meals 2. Eating small, frequent, bland meals 3. Raising the head of the bed on 6-inch blocks 4. Taking histamine receptor antagonist medication, as prescribed 2 Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm, where the esophagus usually is positioned. The client generally experiences pain caused by reflux resulting from ingestion of irritating foods, lying flat following meals or at night, and consuming large or fatty meals. Relief is obtained by eating small, frequent, and bland meals; histamine antagonists and antacids; and elevation of the thorax after meals and during sleep.

The nurse will be providing postprocedure care to a client who has undergone esophagogastroduodenoscopy (EGD). Based on the procedure done, the nurse would plan to do which action first?

1. Measure the client's temperature. 2. Give warm gargles for sore throat. 3. Monitor for return of the gag reflex. 4. Monitor for complaints of heartburn. 3 The nurse should place highest priority on monitoring for return of the gag reflex, which is part of managing the client's airway. The client's vital signs should be monitored next; a sudden, sharp increase in temperature could indicate perforation of the gastrointestinal tract. (This would be accompanied by other signs, such as pain.) Monitoring for sore throat and heartburn also is important but is of lesser priority than monitoring the client's airway.

The nurse understands that the client with a Clostridium difficile (C. difficile) infection is at increased risk for which acid-base imbalance?

1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 1 C. difficile causes frequent episodes of watery diarrhea. The client is at risk for metabolic acidosis, as bicarbonate is lost through the lower gastrointestinal tract.

The nurse caring for a client with a small bowel obstruction monitors for complications of this condition. Which acid-base imbalance would the nurse most likely expect to occur in this condition?

1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 2 Dehydration and electrolyte imbalances, as well as acid-base imbalances, are common for clients with bowel obstruction. A client with an upper bowel obstruction is more likely to have metabolic alkalosis usually due to vomiting and loss of acids, while a client with a lower obstruction is at greater risk for metabolic acidosis. The small bowel is part of the upper bowel. Respiratory acidosis and alkalosis are not specifically related to bowel obstruction.

The client in an emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply

1. Milk of magnesia 2. Heat pad to the abdomen 3. Cold pack to the abdomen 4. Nothing per mouth (NPO)5Intravenous fluids at a rate of 100 mL/hr 4 A client with right lower quadrant abdominal pain may have appendicitis. This client would be NPO and given intravenous (IV) fluids for hydration. Cold packs may provide comfort. Laxatives are not prescribed; heat might bring enough blood and fluid to the appendix to cause it to rupture and cause peritonitis; therefore, the nurse would question the cathartic prescription and heat application.

The nurse is caring for a client in the emergency department who has right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse would question which prescription?

1. Milk of magnesia 2. Nothing per mouth (NPO) 3. Cold pack to the abdomen 4. Intravenous (IV) fluids at a rate of 100 mL/hr 1 A client with right lower quadrant pain may have appendicitis. This client should be NPO and given IV fluids for hydration. Cold packs may provide comfort. Laxatives are not prescribed; therefore, the nurse should question this prescription.

A primary health care provider asks the nurse to obtain a Salem sump tube for gastric intubation for a client with a bowel obstruction. The nurse would select which tube from the unit storage area?

1. Miller-Abbott tube 2. Sengstaken-Blakemore tube 3. Tube with just a single lumen 4. Tube with a lumen and an air vent 4 A Salem sump tube is used commonly for gastric intubation and has a large suction lumen and a small air vent. A Sengstaken-Blakemore tube is a tube used for gastroesophageal bleeding and has a balloon that controls bleeding. A Miller-Abbott tube is a long double-lumen tube used to drain and decompress the small intestine. Option 3 describes a Levin tube. A Levin tube does not have an air vent but is used for the same functions as a Salem sump tube.

The nurse working on the medical-surgical unit admits a client with acute appendicitis scheduled for an appendectomy the following morning. Which interventions would the nurse implement in managing care for this client in the pre-operative period? Select all that apply

1. Monitor vital signs 2. Administer antiemetics 3. Administer pain medications 4. Administer intravenous fluids 5. Nothing by mouth (NPO) status 6. Insert an indwelling urinary catheter 1,2,3,4,5 Ongoing assessment and vital signs would be conducted to determine change in clinical status and detect deterioration. Antiemetics and pain medications are administered as needed for comfort. Intravenous fluids are administered to prevent fluid volume deficit. NPO status is instituted prior to surgery so the stomach is empty and the risk for aspiration during surgery is decreased. An indwelling urinary catheter is not usually required prior to this surgery.

A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse assisting with caring for the client would take which action to monitor the effectiveness of treatment?

1. Monitoring the leukocyte count for 2 days after the infusion 2. Checking the frequency and consistency of bowel movements 3. Checking serum liver enzyme levels before and after the infusion 4. Carrying out a Hematest on gastric fluids after the infusion is completed 2 The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication.

A client has undergone esophagogastroduodenoscopy (EGD). The nurse would place highest priority on which action as part of the client's care plan?

1. Monitoring the temperature 2. Checking for return of a gag reflex 3. Giving warm gargles for a sore throat 4. Monitoring for complaints of heartburn 2 The nurse places highest priority on managing the client's airway. This includes assessing for return of the gag reflex. The client's vital signs are also monitored, and a sudden sharp increase in temperature could indicate perforation of the gastrointestinal (GI) tract. This should be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway still takes priority.

The nurse would reinforce instructions to a client that has had a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information?

1. Most diets are deficient in all of the B vitamins. 2. Once symptoms are evident, pernicious anemia is often fatal. 3. Symptoms can occur as long as 10 years after gastric surgery. 4. Regular monthly injections of vitamin B12 will prevent this complication. 4 Vitamin B12 deficiency occurs from the lack of intrinsic factor normally secreted by specialized cells in the gastric mucosa. Replacement therapy is given by the parenteral route. Symptoms generally occur within 5 years or less. Although not fatal, pernicious anemia can contribute to many other diseases. Not all diets are deficient in all of the B vitamins.

The nurse is reviewing the primary health care provider's (PHCP'S) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription would the nurse verify if noted in the client's chart?

1. NPO status 2. An anticholinergic medication 3. Supine and flat client positioning 4. Insertion of a nasogastric tube 3 The pain associated with acute pancreatitis is aggravated when the client lies in a supine and flat position. Therefore, the nurse would verify this prescription. Options 1, 2, and 4 are appropriate interventions for the client with acute pancreatitis.

The nurse is assisting in caring for a client who suffered blows to the face with a baseball bat and a gunshot wound to the abdomen. The nurse is reviewing the prescriptions in the client's medical record and determines there is a need for follow-up with the primary health care provider if which prescription is noted?

1. Nasogastric tube insertion 2. Obtain a type and crossmatch 3. Obtain a complete blood cell count (CBC) 4. Administration of warm intravenous (IV) fluids 1 Nasogastric tube insertion is contraindicated in the client that has evidence of facial trauma, such as the client that received blows to the face with a blunt object, because it could cause more harm. The nurse would contact the primary health care provider regarding this prescription, as this is an unsafe intervention for this client. Obtaining a type and crossmatch and a CBC are appropriate nursing interventions. Warm IV fluids would help prevent hypothermia in the trauma client.

The nurse is caring for a client with a small bowel obstruction. The nurse would notify the surgeon based on which findings noted on the physical assessment?

1. Nausea 2. Nondistended abdomen 3. Hypoactive bowel sounds 4. Muscle guarding on palpation 4 Bowel obstruction can be a life-threatening condition, and therefore careful assessment and ongoing monitoring is necessary to recognize signs of deterioration. Muscle guarding and rebound pain can be indicative of peritoneal irritation, a resulting complication of the obstruction; the surgeon should be notified of this finding. Nausea and hypoactive bowel sounds are common with this condition and do not necessitate notification of the surgeon. A nondistended abdomen is a reassuring finding.

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client?

1. Soft custard 2. Orange juice 3. Clam chowder 4. Fat-free beef broth 4 A clear liquid diet consists of foods that are relatively transparent. Soft custard and orange juice would be included in a full liquid diet because they are opaque, not clear. Clam chowder is opaque and also includes pieces of clams, thus eliminating it from a full liquid diet.

A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data collection, the nurse notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5 days. Which would be appropriate as the initial nursing action?

1. Notify the registered nurse of the findings. 2. Encourage the client to cough and deep breathe. 3. Check the client's medication prescriptions for a diuretic. 4. Slow the parenteral nutrition infusion rate to 100 mL/hr. 1 The client is showing signs of fluid retention and possible excess fluid intake. Crackles, edema, and weight gain signify fluid shifts from intravascular spaces to the interstitial spaces. The problem may or may not be related to the parenteral nutrition. Other possible causes of fluid retention include impaired respiratory and cardiovascular function, impaired kidney function, or a combination of factors. The nurse needs to notify the registered nurse of the findings. The registered nurse will then notify the primary health care provider for further prescriptions. Option 2 will have little, if any, effect on peripheral edema and weight gain. Option 3 infers that a diuretic will help the situation, and it is possible that the primary health care provider will prescribe a diuretic; however, the primary health care provider needs to be aware of the change in the physical condition of the client. The nurse should not increase or decrease the rate of parenteral nutrition infusions without a primary health care provider's prescription to do so.

Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding?

1. Observe the digestion of formula. 2. Check fluid and electrolyte status. 3. Evaluate absorption of the last feeding. 4.Confirm proper nasogastric tube placement. 1 All the stomach contents are aspirated and measured before administering a tube feeding. This procedure measures the gastric residual volume. The gastric residual volume is checked to confirm whether undigested formula from a previous feeding remains and thereby evaluates the absorption of the last feeding. It is important to check the gastric residual before administration of a tube feeding. A full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. If residual feeding is obtained, the PHCP's prescription and agency policy are checked to determine the course of action (hold or reduce the volume of the intermittent tube feeding).

The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. When planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa?

1. Offer small sips of water frequently. 2. Encourage the client to suck on sour, hard candy. 3. Use lemon glycerin swabs to provide oral hygiene. 4. Use diluted mouthwash and water to swab the mouth after brushing teeth. 4 After the nasogastric tube is in place, mouth care is extremely important. With one naris occluded, the client tends to mouth breathe, drying the mucous membranes. Frequent oral hygiene may be required to prevent or care for dry, irritated mucous membranes. Frequent, small sips of water would be contraindicated when the client is on gastric suction. The hard candy would increase the salivation but would not be useful in cleaning the oral cavity. Lemon glycerin swabs have a drying or irritating effect on the mucous membranes.

A client with a diagnosis of viral hepatitis has no appetite, and food makes the client nauseated. The nurse would conclude that which intervention is most appropriate?

1. Offer small, frequent meals. 2. Encourage foods low in calories. 3. Explain that high-fat diets are usually better tolerated. 4. Explain that the majority of calories needs to be consumed in the evening hours. 1 If nausea persists, the client will need to be assessed for fluid and electrolyte imbalances. It is important to explain to the client that the majority of calories should be eaten in the morning hours because nausea most often occurs in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

The nurse is caring for a client that received a new diet prescription from the primary health care provider (PHCP) for nothing-by-mouth (NPO) except ice chips. Which actions would the nurse take to alleviate the effects of dehydration? Select all that apply.

1. Offer the client small sips of water 2. Observe mucous membranes for drynessisinterest 3. Increase the rate of intravenous (IV) fluids 4. Provide frequent oral care with moist swabs 5. Apply lubricant to the lips and oral mucous membranes 2,4,5 The nurse needs to be aware of the various kinds of diet prescriptions and which items are permitted in each. An NPO except ice chips prescription means that the only substance the client is permitted to consume orally is ice chips. Therefore, option 1 would be an incorrect nursing action. Option 2 would provide the nurse with client data to determine if the client is experiencing dehydration, as the mucous membranes are normally wet and not dry. Option 3 is incorrect because the nurse cannot increase the rate of IV fluids without a PHCP's prescription. Option 4 is a correct nursing action as providing frequent oral care with moist swabs will help to maintain moisture in the mouth. Option 5 is a correct nursing action because applying lubricant to the lips and oral mucous membranes will prevent drying out and cracking of the lips and mucosa.

A morbidly obese client, 3 days postoperative gastric bypass surgery, comes to the clinic complaining of pain. The nurse suspects that the client has an anastomotic leak requiring hospitalization. The nurse would determine that which findings best validate this suspicion? Select all that apply.

1. Oliguria 2. Restlessness 3. Abdominal pain 4. Nausea and vomiting 5. Unexplained tachycardia 1,2,3,5 Oliguria results from the leaking of fluids into the abdomen. Restlessness occurs as the body tries to compensate. Abdominal pain occurs not only from the surgery but also from the leakage. Unexplained tachycardia occurs as a compensatory mechanism for the leakage. Nausea and vomiting occur in clients after gastric bypass surgery if they ingest too much fluid, but they are not as likely to occur with an anastomotic leak and would not be indicators of an anastomotic leak.

Implemented treatment measures for a client with a diagnosis of bleeding esophageal varices have been unsuccessful. The primary health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse would prepare for insertion of this tube via which route?

1. Oralgastric 2. Nasogastric 3. Gastrostomy 4. Percutaneous 2 A Sengstaken-Blakemore tube is inserted via the nose into the esophagus and stomach. The other options are incorrect, because this tube is not inserted in those manners.

The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to digest food. The nurse determines that which processes are involved in the complete digestive process? Select all that apply.

1. Osmosis 2. Chemical 3. Filtration 4. Absorption 5. Mechanical 6. Active transport 2,4,5,6 Digestion is the mechanical and chemical process involving the breakdown of foods. Absorption is the transfer of digested food elements into the bloodstream. The blood then carries nutrients to the cells. Active transport is the process used to transfer nutrients into the cells. Options 1 and 3 are incorrect.

The nurse is caring for a client with a diagnosis of pneumonia and a history of bleeding esophageal varices. Based on this information, the nurse would plan care knowing that which could most result in a potential complication?

1. Pain 2. Diarrhea 3. Frequent swallowing 4. Vigorous coughing 4 Increased intrathoracic pressure contributes to rupturing of varices. Straining at stool, coughing, and vomiting all increase intrathoracic pressure. The nurse needs to implement measures that will prevent increased intrathoracic pressure. Options 1, 2, and 3 will not increase intrathoracic pressure.

The nurse is caring for a postoperative client who had a colon resection for colon cancer. Which complication is most likely to occur after this procedure?

1. Paralytic ileus 2. Pseudo-obstruction 3. Vascular obstruction 4. Mechanical obstruction 1 Paralytic ileus occurs when there is a lack of peristalsis and is characterized by a lack of bowel sounds on auscultation. This is a type of nonmechanical obstruction that occurs after abdominal surgery. Pseudo-obstruction and vascular obstruction are types of mechanical obstruction. Pseudo-obstruction occurs without any identifiable cause, and vascular obstruction is found when there is a lack of blood supply to an affected area of the bowel.

The nurse is assisting in assessing a client who was in a motor vehicle crash and experienced blunt trauma to the abdomen. The nurse is told that on auscultation of the abdomen, a bruit is heard. Which complication would the nurse suspect?

1. Peritonitis 2. Paralytic ileus 3. Aortic aneurysm 4. Rupture of the diaphragm 3 Bruits are an abnormal assessment finding and indicate turbulent blood flow. Bruits can indicate an aneurysm is present or arterial damage has occurred, which can happen after abdominal trauma. An abdominal computed tomography (CT) scan or abdominal ultrasound may be done to confirm the diagnosis. Peritonitis would not be present with a bruit upon abdominal auscultation. Absent bowel sounds would be present with a paralytic ileus. Bowel sounds would be auscultated in the chest if diaphragmatic rupture occurred.

A client arrives at the emergency department complaining of severe abdominal pain and is placed on NPO status. During a quick assessment the nurse observes that the client has both Cullen's sign and Grey Turner's sign, and pancreatitis is suspected. The nurse would assist to implement which action first?

1. Place a nasogastric tube. 2. Hydrate the client with intravenous fluids. 3. Ensure the client receives intravenous pain medication. 4. Obtain vital signs and draw blood for laboratory analysis. 4 The first priority is to confirm the suspicion that the client has acute pancreatitis. Lipase, amylase, trypsin, elastase, and glucose elevations can all indicate pancreatic cell injury. Baseline vital signs are also essential. Vital signs can indicate fluid volume shifts or hemorrhage. Next, intravenous opiates are the choice for severe abdominal pain because they have a fast onset and also do not stimulate release of pancreatic digestive enzymes as an oral pain medication would. The client should be dehydrated next because of the pancreatic injury. Lastly the placement of a nasogastric tube allows for decompression of the abdomen and drainage of contents as needed.

he nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?

1. Placement is verified on x-ray. 2. The pH of the aspirated fluid is 5. 3. The aspirated fluid is bile green in color. 4. Air injection is auscultated in the left upper quadrant. 3 The end of the NG tube should be in the stomach. An x-ray is the most reliable method of determining correct placement. The radiologist may recommend moving the tube backward or forward for a preferable placement. A low pH such as 4.5 of the fluid aspirated is likely to be from the stomach, but pH is affected by tube feeding formulas and prescribed proton-pump inhibitors. The characteristic bile green is highly suggestive that the tube is in the stomach. Auscultation of the air injection is not recommended as a reliable method to establish correct placement.

The nurse has a prescription to give 30 mL of an antacid through a nasogastric (NG) tube connected to wall suction. The nurse would do which best action to perform this procedure correctly?

1. Position the client supine to assist in medication absorption. 2. Aspirate the NG tube following medication administration to maintain patency. 3. Clamp the NG tube for 30 minutes following administration of the medication. 4. Adjust the suction to a low-intermittent setting for an hour after medication administration. 3 If a client has an NG tube connected to suction, the nurse clamps the tube and waits 20 to 30 minutes before reconnecting the tube to the suction. This allows adequate time for medication absorption. Options 2 and 4 both result in removal of the medication that has just been administered. The client should not be placed in the supine position because of risk of aspiration.

The nurse is caring for a client with a diagnosis of acute appendicitis. Which physical assessment finding consistent with this diagnosis would the nurse expect to be documented in the client's medical record?

1. Positive Murphy's sign 2. Positive Romberg's sign 3. Pain at McBurney's point 4. Positive anterior drawer test 3 Appendicitis usually starts with dull pain in the periumbilical area associated with diminished appetite and sometimes nausea and vomiting. The pain is characterized as persistent and continuous and then shifts later to the right lower quadrant at McBurney's point, which is between the umbilicus and right iliac crest. Murphy's sign is used to aid in diagnosing cholecystitis and is present when there is tenderness on the inspiratory pause and is elicited during palpation of the right upper quadrant. The Romberg's sign is used to test proprioception and is positive when there is a loss of balance when the client closes their eyes. A positive anterior drawer test is found when the shin bones move more on an injured leg compared to an uninjured leg and is used to assess for anterior cruciate ligament (ACL) stability.

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which?

1. Promote bile flow 2. Limit client discomfort 3. Promote hepatic glucose storage 4.Limit bleeding from the biopsy site 4 After a liver biopsy, the client is assisted with assuming a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours to apply pressure and limit bleeding from the biopsy site. The liver produces bile that flows through the common bile duct; client discomfort may be decreased; and the liver does store glucose as glycogen, but this is not the purpose of the right side-lying position.

The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia would the nurse reinforce to the client? Select all that apply.

1. Provide meticulous and frequent oral hygiene. 2. Use additional lightweight blankets as needed. 3. Encourage a diet of foods with high iron content. 4. Check blood serum vitamin B12 levels every 1 to 2 years. 5. Administer replacement vitamin B12 monthly for the next 5 years. 1,2,4 Vitamin B12 deficiency occurs from lack of intrinsic factor normally secreted by specialized cells in the gastric mucosa. Meticulous frequent oral hygiene will promote an improved appetite and prevent infection. The client has a sensitivity to cold, so additional blankets may be needed. Serum blood vitamin B12 levels need to be checked every 1 to 2 years to make sure replacement therapy is adequate. A diet high in iron content is appropriate for iron deficiency anemia rather than vitamin B12 deficiency. Replacement therapy is given for a lifetime, not just 5 years.

The nurse is caring for a client with a Sengstaken-Blakemore tube. To effectively prevent ulceration and necrosis of oral and nasal mucosa, the nurse would plan to implement which action?

1. Provide tracheal suction as needed. 2. Keep scissors at the bedside for emergency deflation. 3. Provide frequent oral and nasal care on a regular basis. 4. Have a family member remain with the client as much as possible. 3

The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, the nurse would focus on which priority intervention?

1. Providing the client with an oral diet 2. Maintaining a patent nasogastric (NG) tube 3. Promoting the use of stress reduction techniques 4. Teaching the client about the symptoms of dumping syndrome 2 An NG tube is inserted during surgery and is left in place for 24 to 48 hours to decompress the gastrointestinal tract, which enhances sealing of the suture line. It is essential that the NG tube does not become occluded because this could disrupt the suture lines if distention occurs. The other options are also appropriate, but not within the first 24 hours following surgery.

The nurse is collecting data on a client admitted to the hospital with a diagnosis of hepatitis. The nurse would determine which data indicates the client may have liver damage?

1. Pruritus 2. Cool dry skin 3. Dark brown stools 4. Yellow, straw-colored urine 1 Significant damage to liver cells renders them unable to metabolize bilirubin. When a red blood cell is broken down, hemoglobin is released. The heme portion is catabolized into unconjugated bilirubin. The liver then takes that unconjugated bilirubin and transforms it into conjugated bilirubin that passes into the hepatic ducts and eventually into the bowel, providing the normal brown color to stool. When bilirubin is not metabolized by the liver, it accumulates in the circulation and is minimally excreted by the skin, causing jaundice and pruritus. It is also eliminated unchanged by the kidneys, causing urine to become dark amber or brown.

The nurse is caring for a client with a diagnosis of acute anal fissure. Which characteristic assessment finding would the nurse expect to note?

1. Recent constipation 2. Use of fiber supplements 3. Perianal pain while standing 4. Presence of perianal skin tag 1 Constipation, or the passage of hard stool, is the most common cause of anal fissure. Use of fiber supplements help with preventing constipation and thereby help to prevent anal fissures. Other findings include pain with defecation and direct pressure on the site such as with sitting down. Acute anal fissures look like an ulceration in the lining of the anal tissue. Chronic anal fissures often have a fibrotic appearance with formation of a skin tag in the area.

The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. The nurse would determine that which data noted in the record indicate poor absorption of dietary fats?

1. Steatorrhea 2. Bloody diarrhea 3. Electrolyte disturbances 4. Gastrointestinal reflux disease 1 The pancreas makes digestive enzymes that aid absorption. Chronic pancreatitis interferes with the absorption of nutrients. Fat absorption is limited because of the lack of pancreatic lipase. Steatorrhea by definition is excess fat in stools often caused by malabsorption problems. Options 2, 3, and 4 are rarely associated with chronic pancreatitis.

The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to absorb food. While doing this, the nurse recalls that absorption is most concerned with which bodily function?

1. Removal by osmosis of digested food to the cells 2. The chemical process involving the breakdown of foods 3. The transfer of nutrients into the cell by active transport 4. The transfer of digested food molecules from the GI tract into the bloodstream 3 Absorption is the transfer of digested food elements into the bloodstream. The blood then carries nutrients to the cells. Active transport is the process used to transfer nutrients into the cells. Digestion involves the mechanical and chemical breakdown of foods. Option 1 is an incorrect statement.

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. Which interventions would be included in the procedure? Select all that apply.

1. Remove the air from the balloon. 2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continuous steady motion. 5. Remove the device or tape securing the tube from the nose. 2,3,4,5 Before removing the tube, the client should be told about the procedure and review the instructions. The tape or securing device needs to be removed from the client's nose. When the NG tube is removed, the client is instructed to take and hold a deep breath. This will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with one very smooth, continuous pull. There is no balloon that needs to be deflated on an NG tube.

The nurse is reinforcing discharge instructions to a client who has had a total gastrectomy. The nurse instructs the client about the importance of returning as scheduled to the health care clinic for which priority assessment?

1. Renal function studies 2. Gastric analysis studies 3. Vital sign measurements 4. Vitamin B12 and folic acid studies 4 Common nutritional problems following stomach removal include vitamin B12 and folic acid deficiency. This may result from a deficiency of an intrinsic factor and/or inadequate absorption because food enters the bowel too quickly. Option 3 may be a component of the assessment at a follow-up health care visit but is not a priority assessment. Options 1 and 2 are not necessary studies following a total gastrectomy.

The nurse has been providing care for a client with a Sengstaken-Blakemore tube. While the tube is inflated the nurse would monitor for which priority sign/symptom?

1. Respiratory distress 2. A rise in the pulse rate 3. Elevated blood pressure 4. An elevated temperature 1 A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices when other measures used to treat the varices are unsuccessful or contraindicated for the client. When the balloon on the tube is inflated, the nurse should monitor for respiratory distress, which could indicate the balloon has ruptured.

The nurse is assisting in planning stress management strategies for the client diagnosed with irritable bowel syndrome. Which suggestion is most appropriate for the nurse to give to the client?

1. Rest in bed as much as possible. 2. Limit exercise to reduce bowel stimulation. 3. Try to avoid every possible stressful situation. 4. Learn measures such as biofeedback or progressive relaxation. 4 Treatment for irritable bowel syndrome includes stress reduction measures such as biofeedback, progressive relaxation, and regular exercise. The client should also learn to limit responsibilities. Other measures include increased fluid and fiber in the diet as prescribed and antispasmodic or sedative medications as needed.

The nurse is teaching a client with irritable bowel syndrome (IBS) about food items that may exacerbate the condition. The nurse identifies a need for further teaching if the client states which food item is acceptable to consume?

1. Rice cakes 2. Cauliflower 3. Potato chips 4. Cranberry juice 4 Clients with IBS would be taught to eat a diet that is gluten-free and is low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs). Cauliflower contains large amounts of polyols and therefore needs to be avoided.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a modified left lateral recumbent position. The nurse explains that this positioning is preferred because of which reason?

1. Right side 2. Low-Fowler's position 3. High-Fowler's position 4. Supine, with the head flat 3 Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be placed behind the head and shoulders to promote the client's ability to swallow during procedure. Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.

The client admitted to the hospital with a diagnosis of viral hepatitis is complaining of a loss of appetite. In order to provide adequate nutrition, which action would the nurse encourage the client to take?

1. Select foods high in fat. 2. Increase intake of fluids. 3. Eat less often, preferably only three large meals daily. 4. Eat a large supper when anorexia is most likely not as severe. 2 Although no special diet is required in the treatment of viral hepatitis, it is generally recommended that clients have a diet with low-fat content because fat may be poorly tolerated due to decreased bile production. Small frequent meals are preferable and may even prevent nausea. Often, the appetite is better in the morning, so it is easier to eat a healthy breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional fluids is also important.

The nurse is providing care for a client with with ulcerative colitis who underwent the creation of a transverse colostomy. Which observation requires immediate notification of the surgeon?

1. Stoma is beefy red and shiny 2. Stoma has a purple discoloration 3. Skin excoriation is noted around the stoma 4. Semiformed stool is noted in the ostomy pouch 2 Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semiformed stool is a normal finding.

A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?

1. Sepsis 2. Air embolism 3. Fluid overload 4.Hyperglycemia1. 3 The client's signs and symptoms are consistent with fluid overload. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. A fever would be present in a client with sepsis. Signs and symptoms of an air embolus include confusion, pallor, lightheadedness, tachycardia, tachypnea, hypotension, anxiety, and unresponsiveness. Polyuria, polydipsia, and polyphagia are manifestations of hyperglycemia.

The nurse assigned to care for a client diagnosed with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing?

1. Sims 2. Prone 3. Supine 4. Semi-Fowler's 4 The client experiencing difficulty maintaining an effective breathing pattern due to pressure on the diaphragm should be placed in a semi-Fowler's or Fowler's position. The nurse should support the client's arms and chest with pillows to facilitate breathing by relieving pressure on the diaphragm. The supine, Sims', and prone positions all are flat positions and would further affect the breathing pattern in the client.

The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse would place the client in which position during and after the feedings?

1. Sims 2. Supine 3. Fowler's 4. Trendelenburg's 3 The client is placed with the head of the bed elevated 30 to 45 degrees both during and after feedings to prevent aspiration. The Sim's, supine, and Trendelenburg's positions place the client at risk for aspiration.

A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN would assist the client into which most appropriate position?

1. Sims' 2. Supine with the head and feet flat 3. Supine with the head raised slightly and the knees slightly flexed 4. Semi-Fowler's with the head raised 45 degrees and the knees flat 3 To perform an abdominal assessment, the client is placed in the supine position with the head raised slightly and the knees slightly flexed. This position will relax the abdominal muscles. If the head is raised to 45 degrees, the abdomen cannot be accurately assessed. The Sims' position is a side-lying position and does not adequately expose the abdomen for examination. Placing the head and feet flat results in the abdominal muscles becoming taut.

A client diagnosed with acute pancreatitis is experiencing severe pain from the disorder. The nurse would instruct the client to avoid which position that could aggravate the pain?

1. Sitting up 2. Lying flat 3. Leaning forward 4. Flexing the left leg 2 Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) may alleviate some of the pain associated with pancreatitis. The pain is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior peritoneal wall with these positions.

A client has undergone subtotal gastrectomy, and the nurse is preparing the client for discharge. Which item would be included when reinforcing instructions to the client about ongoing self-management?

1. Smaller, more frequent meals should be eaten. 2. The client can resume full activity immediately. 3. Stress can no longer exacerbate gastrointestinal symptoms. 4. Follow-up visits with the primary health care provider are no longer needed. 1 Following gastric surgery the client should eat smaller, more frequent meals to facilitate digestion. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client does require ongoing medical supervision and evaluation.

The nurse would include which instruction in a teaching plan for a client who has been diagnosed with peptic ulcer disease?

1. Smoke at bedtime only. 2. Learn to use stress reduction techniques. 3. Continue to eat the same diet as before the diagnosis. 4. Take nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief. 1 Identifying and reducing stress are essential to a comprehensive ulcer management plan. The client should also limit intake of foods that aggravate pain, quit smoking, and avoid irritants such as NSAIDs. Antibiotic therapy is often prescribed to treat this disease.

The nurse would recognize that which type of enema has the highest risk of water intoxication?

1. Soapsuds 2. Tap water 3. Normal saline 4. Hypertonic solution 2 Tap water is hypotonic, creating a lower osmotic pressure than the fluid in interstitial spaces. With repeated tap water enemas, fluid can escape from the bowel lumen into interstitial spaces and can cause circulatory overload or water intoxication if the body absorbs too much water. Normal saline enemas are the safest type of enema because of having the same osmotic pressure as fluid in the interstitial spaces around the bowel. Thus, enemas using normal saline do not cause any fluid shifts but may not be effective in evacuating the bowel. Castile soap is incorrect because it can be mixed with either water or saline, and if mixed with saline, there should not be any risk of fluid overload. Castile soap is the only safe soap to use for a soapsuds enema because harsh soaps may cause inflammation of the bowel. Hypertonic solution is incorrect because hypertonic fluids pull fluid from the interstitial spaces into the colon. Although this could have the potential for dehydration, it does not pose as high a risk of complications as the tap water enema. A Fleets enema (commercially prepared sodium phosphate) is the most common type of hypertonic enema.

The nurse is caring for a client with a diagnosis of dehydration. Which laboratory finding, as noted in the client's medical record, supports this diagnosis?

1. Sodium level of 127 mEq/L (127 mmol/L) 2. Sodium level of 135 mEq/L (135 mmol/L) 3. Sodium level of 142 mEq/L (142 mmol/L) 4. Sodium level of 149 mEq/L (149 mmol/L). 4 Dehydration is characterized by a loss of pure water alone without the corresponding loss of sodium. In dehydration, the nurse would note an increase in the serum sodium level above normal limits.

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. The nurse would take which appropriate action?

1. Stop the irrigation temporarily. 2. Increase the height of the irrigation. 3. Medicate for pain and resume irrigation. 4. Notify the registered nurse immediately. 1 If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigation will cause further discomfort. The registered nurse does not need to be notified immediately. Medicating the client for pain is not the appropriate action.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?

1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain 1

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence?

1. Sweating and pallor 2. Dry skin and stomach pain 3. Bradycardia and indigestion 4. Double vision and chest pain 1 Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse would take which immediate action?

1. Take the client's vital signs. 2. Perform a complete abdominal assessment. 3. Obtain a thorough history of the recent health status. 4. Prepare to insert a nasogastric (NG) tube and test pH and occult blood. 1 The nurse should take the client's vital signs first to determine if the client is hypovolemic or in shock from blood loss; this also provides a baseline blood pressure and pulse by which to gauge the effectiveness of treatment. Signs and symptoms of shock include low blood pressure; rapid, weak pulse; increased thirst; cold, clammy skin; and restlessness. The registered nurse also is notified. Although an NG tube may be inserted, this is not the immediate action. A complete history would be obtained and an abdominal assessment would be done once the client is stable.

The nurse is assigned to care for a client receiving total parenteral nutrition via the subclavian vein. The nurse would identify which intervention in the plan of care for the client as the priority?

1. Taking the blood pressure hourly 2. Monitoring the insertion site for signs of infection 3. Encouraging the client to cough and deep breathe 4. Maintaining the client in a semi-Fowler's position on his back at all times 2 Total parenteral nutrition that is infusing via a central line, such as through the subclavian vein, is more likely to become infected than a standard peripheral intravenous line. Infection may quickly lead to sepsis. At least every 4 to 6 hours, the insertion site should be inspected. It is not necessary to place the client in the semi-Fowler's position on his back at all times. It is advisable to encourage a client to cough and deep breathe, but this action does not relate to the subject of the question. It is not necessary to take the blood pressure hourly.

The nurse is caring for a client with a nasogastric (NG) tube and tests the pH of the aspirate to determine correct placement. The test results indicate a pH of 5. The nurse would determine this indicates which information?

1. The NG tube needs to be reinserted. 2. Placement of the NG tube is accurate. 3. The pH of the aspirate needs to be rechecked. 4. The NG tube needs to be pulled back approximately 1 inch. 2 After the nurse inserts an NG tube into a client, the correct location of the tube must be verified. Testing the pH of the gastric fluid and determining its acidity further verifies that the tube is in the stomach. The stomach contents are acidic, and a pH of 5 should indicate accurate placement. Reinserting the NG tube, rechecking the pH of the aspirate, and pulling the NG tube back are incorrect.

The nurse is providing care for a client with a nasogastric tube. Which observation is most appropriate in determining that the tube is correctly placed?

1. The aspirate is dark green. 2. The pH of the aspirate is 5. 3. The aspirate is negative for guaiac. 4. The tube length was correctly measured before insertion. 5 After the nurse inserts a nasogastric tube into a client the correct location of the tube must be verified. The nurse follows the approved procedure for inserting a nasogastric tube including correct measurement and aspirating fluid with the visible characteristics of gastric fluid. The presence of blood (option 3) is unrelated to the location of the tube. Aspirate is dark green and the tube is inserted the length measuring from the client's ear to nose and nose to xiphoid process. However, testing the pH of the gastric fluid and determining its acidity is the most reliable verification that the tube is correctly placed.

A nurse is doing an assesment on a patient for dehydration. Which of the following conditions could possibly cause dehydration? Select all that apply.

1. The client with dementia 2. The client with a clamped nasogastric tube 3. The client with Clostridium difficile infection 4. The client whose blood glucose level is 75 mg/dL (4.1 mmol/L) 5. The client in acute heart failure exacerbation taking furosemide 1,3,5 Dehydration is the loss of fluid without a corresponding loss of sodium. Conditions that put a client at risk for dehydration include dementia, as the client may not feel the sensation of thirst. Clostridium difficile causes multiple episodes of watery diarrhea, which can cause dehydration, and the administration of diuretics such as furosemide causes increased urine output, which predisposes the client to dehydration. The client with an unclamped nasogastric tube attached to suction is at risk for dehydration, not a client with a clamped nasogastric tube. A client with an elevated blood glucose level is at risk for dehydration related to polyuria, not a client with a blood glucose within normal limits, which is 70-99 mg/dL (3.9-5.5 mmol/L).

A client is receiving total parenteral nutrition and has been NPO. The primary health care provider (PHCP) prescribed small amounts of clear liquids today. The nurse's priority is to collect data regarding which criterion before giving the client anything by mouth?

1. The client's appetite 2. The client's current weight 3. The presence of the swallow reflex 4. Adequate pulse and blood pressure readings 3 The nurse ensures that the client has intact gag and swallow reflexes before giving clear liquids. The nurse should also check for the presence of bowel sounds. The pulse, blood pressure, and weight require ongoing monitoring, but they are not the most important items given the wording of the question. The client may be expected to have a poor appetite after being without oral intake for a period of time.

The nurse is assessing a client with a suspected Clostridium difficile infection. The nurse notes that which clinical manifestations are consistent with this diagnosis? Select all that apply.

1. The client's temperature is 101.7°F (38.2°C). 2. The client is having watery bowel movements. 3. Stool culture negative for white blood cells (WBCs). 4. The client has consumed 100 percent of all daily meals. 5. The client grimaces while the nurse palpates the abdomen. 1,2,5 The clinical manifestations of a Clostridium difficile infection include fever, watery diarrhea, and abdominal pain. Therefore, options 1, 2 and 5 are correct. A stool culture is usually positive for white blood cells in the presence of a Clostridium difficile infection; therefore option 3 is incorrect. Option 4 is incorrect because the client with a Clostridium difficile infection experiences anorexia rather than a good appetite.

The nurse is caring for a client diagnosed with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed the nasogastric tube to be discontinued. To best determine the client's readiness for discontinuation of the nasogastric tube, which measure would the nurse check?

1. The pH of the gastric aspirate 2. Proper nasogastric tube placement 3. The client's serum electrolyte levels 4. Presence of bowel sounds in all four quadrants 4 Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction, and a nasogastric tube may be used to empty the stomach and relieve distention and vomiting. Bowel sounds return to normal as the obstruction is relieved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function returns may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, tube placement, and pH of gastric aspirate are important assessments for the client with a nasogastric tube in place, but these would not assist in determining the readiness for removing the nasogastric tube.

The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client would the nurse recognize as best supporting the diagnosis of gastric ulcer?

1. The pain doesn't usually come right after I eat." 2. "The pain gets so bad that it wakes me up at night." 3. "The pain that I get is located on the right side of my chest." 4. "My pain comes shortly after I eat, maybe a half hour or so later." 1 Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by food. The pain occurs a half hour to an hour after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

The nurse is reinforcing instructions to a client about insertion of a Sengstaken-Blakemore tube. Which statement by the client indicates a need for further teaching?

1. The tube will be inserted by my primary health care provider. 2. The tube will be inserted through my nose to my stomach. 3. The tube will be inserted through my mouth to my stomach. 4. The tube will be inserted to control bleeding of my esophagus. 3 A Sengstaken-Blakemore tube may be used to control bleeding of esophageal varices when other interventions have been ineffective. It is inserted by the primary health care provider via the nose into the esophagus and stomach. The remaining option is incorrect.

A client diagnosed with hepatic encephalopathy is receiving lactulose. The nurse determines that the medication is effective if which finding is observed?

1. There is an absence of blood in emesis and stool. 2. Urine output increases from 250 to 400 mL per 8-hour shift. 3. Episodes of frequent liquid bowel movements diminish to one time per day. 4. The client who was previously oriented to person only can now state name, year, and present location. 4 Hepatic encephalopathy produces alterations in level of consciousness because of the liver's inability to metabolize and cleanse the blood of ammonia and mercaptans. Lactulose is administered to decrease serum ammonia levels by facilitating movement of ammonia from the blood to the stool. Effectiveness is evident if the client has an improvement in level of consciousness.

A client with ulcerative colitis had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

1. This is a normal, expected event 2. The client is experiencing early signs of ischemic bowel 3. The client should not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation. 1 As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations

A client reports excessive sweating, muscular weakness, diarrhea, and achiness in the bones. The nurse suspects the client is deficient in which vitamin?

1. Vitamin K 2. Vitamin D 3. Vitamin C 4. Vitamin B6 2 Muscular weakness, excessive sweating, diarrhea, bone pain, and osteomalacia is associated with vitamin D deficiency. Vitamin K deficiency is associated with dysfunctional blood coagulation. Vitamin C deficiency is associated with bleeding gums, loose teeth, poor wound healing, scurvy, and dry and itchy skin. Vitamin B6 deficiency is associated with seizures, anemia, neuropathy, weakness, and anorexia.

The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse would conclude which is the problem, and what action would be taken?

1. This is a serious complication; the primary health care provider must be notified immediately. 2. It is a normal occurrence for a nasogastric tube to stop draining; no action is required. 3. Thick gastric secretions may be blocking the tube; removing this tube and reinserting a new tube will correct the problem. 4. Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying. 4 The nurse must check nasogastric tubes regularly to maintain the tube's patency and ensure that it is draining properly. Nasogastric tubes are used to decompress the stomach. The gastric distention will be relieved only if the tube drains properly. One cause of improper tube drainage is that channels of gastric secretions form along the walls of the stomach and bypass the holes in the nasogastric tube. Turning the client regularly helps collapse the channels and promotes gastric emptying. The tube already has been flushed, so it is unlikely that it is still blocked by thick secretions. Although this is a problem that requires attention and intervention, it is not a serious complication.

A caregiver states that the client eats only about 25% of the food that is offered and is losing weight. The caregiver asks the nurse about feeding the client by a tube into the stomach. Which initial response by the nurse would be appropriate?

1. Tube feedings are only for long-term feeding problems. 2. Tube feedings can provide adequate amounts of required nutrients. 3. Tube feedings often result in complications such as aspiration pneumonia. 4. Tube feedings are not helpful in cases of intractable vomiting or severe diarrhea." 2 Weight loss and a dietary intake of only 25% indicate that alternative sources of nutritional intake should be sought. Tube feeding is an alternative for temporary or permanent nutritional maintenance. Enteral tube feedings are generally safer and significantly less costly than peripheral or parenteral nutrition. Option 1 is incorrect because tube feedings are often temporary measures. Option 3 may be correct; however, it is not the best response to a caregiver seeking initial information. Option 4 is unrelated to the situation of this question.

The nurse is reviewing the chart for a client with Clostridium difficile (C. difficile) infection. The nurse would contact the primary health care provider (PHCP) regarding which priority finding?

1. Two watery stools in 1 hour 2. Heart rate 102 beats per minute 3. Serum potassium 2.9 mEq/L (2.9 mmol/L) 4. The client reports generalized abdominal pain 3 Rationale:The potassium level of 2.9 mEq/L (2.9 mmol/L) indicates hypokalemia and puts the client at risk for life-threatening cardiac dysrhythmias; potassium needs to be replaced. A heart rate of 102 beats per minute is elevated, however not unexpected in a client that is experiencing dehydration related to frequent diarrhea secondary to a C. difficile infection. The client with a C. difficile infection experiences frequent watery stools; therefore, option 1 is not unexpected. Due to the anatomical location of the infection, generalized abdominal pain is an expected symptom of the infection and is not a priority finding that needs to be reported to the PHCP.

A client with cirrhosis admitted to the hospital diagnosed with severe jaundice is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall to maintain muscle strength. The client paces around the room but will not enter the hall. The nurse would determine which concern is most likely the reason for the client's reluctance to walk in the hall?

1. Unfamiliarity with the hospital 2. Fear of catching another disease 3. Feeling self-conscious about appearance 4. Not wanting to overexert and get overtired 3 Clients with jaundice frequently have a body image disturbance because of a change in appearance. This can be manifested in negative verbal or nonverbal behavior. Unfamiliarity with the hospital, fear of catching another disease, and not wanting to overexert are unrelated to the data in the question.

A primary health care provider is about to perform a paracentesis on a client diagnosed with abdominal ascites. The nurse would assist the client to assume which position?

1. Upright 2. Supine 3. Left side-lying 4. Right side-lying 1 An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. Ideally, the client sits upright in a chair, with feet flat on the floor, and with the bladder emptied before the procedure. Therefore, the supine, left side-lying, and right side-lying positions are incorrect.

After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse would monitor the client closely for which priority esophageal complication?

1. Varices 2. Necrosis 3. Rupture 4. Hemorrhage 4 A Sengstaken-Blakemore tube is inserted in cirrhotic clients with ruptured esophageal varices when other measures are ineffective. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the exiting esophageal varices.

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency?

1. Vitamin A 2. Vitamin C 3. Vitamin E 4. Vitamin B12 4 Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells. When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. Options 1, 2, and 3 are incorrect.

The client has a prescription for sucralfate 1 g by mouth 4 times daily. The nurse would best schedule the administration of the medication at which time?

1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime 4. One hour before meals and at bedtime 4 Sucralfate is a medication that should be scheduled for administration 1 hour before meals and at bedtime. The medication is scheduled so that it has time to form a protective coating over the ulcer before food intake stimulates chemical and mechanical irritation. Therefore, the other options are incorrect.

A client that is postgastrectomy being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I may lose my job." Based on the client's statement, the nurse would determine that at this time, it is most appropriate to discuss which topic?

1. Wound care 2. An exercise program 3. Reducing stressors in life 4. The postgastrectomy diet 3 Some clients need help reducing stressors in their lives. This may be extremely important for recovery. Clients may expect a rapid recovery and are disappointed when this does not occur. The client's statement provides an opportunity for the nurse to discuss stress and its relationship to gastrointestinal disorders. The data in the question are unrelated to wound care, exercise programs, or the postgastrectomy diet.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a modified left lateral recumbent position. The nurse explains that this positioning is preferred because of which reason?

1. nurse is right handed. 2. The rectal sphincter will relax. 3. The enema will flow into the bowel easily. 4. The client is more likely to retain the enema solution. 3 When administering an enema, the client is placed in a modified left lateral recumbent position so that the enema solution can flow by gravity in the natural direction of the colon. The anatomy of the colon consists of ascending on the right, transverse across, with descending on the left leading to the sigmoid and rectum. If the client lies on the left side, the enema solution will flow easily into the bowel. The hand dominance of the nurse is not a factor. The nurse assists the client to relax the rectal sphincter by asking the client to take a deep breath. The nurse assists the client to retain the enema solution by administering the enema slowly. The nurse should also use teach-back to determine client's understanding about the reason for the enema.

The nurse has been reinforcing dietary teaching for a client diagnosed with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client?

1.A decrease in sour eructation 2. Taking in increased dairy products 3. Use of only decaffeinated coffee and tea 4. Decreased use of as-needed (PRN) medications 1 A decrease in sour eructation (burping) represents a change in the client's health status and is an effective indicator of a successful outcome. Options 2 and 3 are not consistent with minimizing disease symptoms. Option 4 represents healthy behavior by the client, but it is not as positive as is the correct option.

The client arrives at the clinic complaining of dyspepsia and pain that occurs about 90 minutes after eating. The client also reports that the pain became worse this afternoon about 3 hours after eating a large bowl of spaghetti with tomato sauce. Laboratory tests reveal the presence of Helicobacter pylori (H. pylori). The nurse anticipates that the primary health care provider would prescribe which medications? Select all that apply. Rationale, Strategy Rationale Strategy Labs Answer Options

1.Esomeprazole 2Metronidazole 3Clarithromycin 4Calcium carbonate 5Hydrocodone and ibuprofen 2,3 The client is describing symptoms associated with a duodenal ulcer. Clarithromycin and metronidazole are two of the antibiotics frequently prescribed to treat H. pylori infection, which is a common cause of duodenal ulcers. A proton pump inhibitor, like esomeprazole, is prescribed to help decrease gastric acid secretions. Tums is contraindicated because it can trigger gastrin release resulting in rebound acid secretion and more pain. The ibuprofen (like all NSAIDs) can aggravate the ulcer.

The nurse is caring for a client with fatty liver disease who is scheduled for a paracentesis to treat ascites. The client has an indwelling urinary catheter in place to aid in the healing of a sacral pressure injury. The nurse assesses the client and would notify the registered nurse regarding which priority finding?

1.The client's abdomen is round and protuberant. 2. The client's last bowel movement was 3 days ago. 3. The client is having difficulty with deep-breathing exercises. 4. The client has pink-tinged urine in the indwelling urinary drainage bag. 4 Ascites is the accumulation of fluid in the peritoneal cavity. If the fluid accumulation is excessive and hindering the client's ability to breathe effectively, it can be removed via paracentesis, in which a catheter is introduced into the peritoneal space to drain the fluid. The client is at risk for bleeding with this procedure, and baseline laboratory values such as a complete blood count (CBC) and coagulation studies should be drawn prior to the procedure. Pink-tinged urine in the urinary drainage bag indicates there is blood present in the urine, which needs to be further investigated, as this could indicate the client is experiencing an underlying bleeding or clotting issue, which would make the paracentesis unsafe. Therefore, option 4 is correct. A round and protuberant abdomen is an expected finding related to ascites. The client's last bowel movement being 3 days ago may need to be addressed at some point soon; however, it is not the priority assessment finding. Difficulty with deep-breathing exercises is not abnormal depending on the degree of fluid accumulation in the peritoneal space, as it inhibits adequate expansion of the diaphragm.

The nurse is monitoring the intake and output of a client diagnosed with fatty liver disease that is exhibiting ascites. The nurse documents that the client has consumed 4 ounces of apple juice and 8 ounces of coffee with breakfast, 8 ounces of water and 8 ounces of tea with lunch, and 10 ounces of water with dinner. Additionally, the client received two doses of intravenous antibiotics mixed in 50 mL of normal saline. Also noted is 675 mL of urine output documented in the client's chart. What is the client's fluid balance in mL? Fill in the blank.

_____________________mL 565 ml To determine fluid balance, the total output should be subtracted from the total intake. Sources of intake include substances that are liquid at room temperature that are ingested orally, as well as fluids given parenterally. Sources of output include urine output, emesis, liquid stool, wound drainage, and gastric or respiratory secretions. The client's total intake is 4 ounces + 8 ounces + 8 ounces + 8 ounces + 10 ounces = 38 ounces. There are 30 ounces in 1 mL, so to convert ounces to mL, multiply 38 ounces by 30 to yield 1,140 mL. Do not forget to add 100 mL to the total to include the two doses of intravenous antibiotics each mixed in 50 mL of normal saline, which yields 1,240 mL. 1,240 mL minus 675 mL of urine output yields 565 mL. Therefore, the client's fluid balance is 565 mL.