Medsurg - GI and heme/onc

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure?

Paracentesis is performed to remove excess fluid from the abdominal cavity or to collect a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Prior to a paracentesis, nursing actions include: -Verify that the client received necessary information to give consent and witness informed consent -Instruct the client to void to prevent puncturing the bladder (Option 5) -Assess the client's abdominal girth, weight, and vital signs (Option 3) -Place the client in the high Fowler position or as upright as possible (Option 4) (Option 1) Paracentesis is an invasive procedure requiring delivery of informed consent by the health care provider (HCP). The HCP explains the benefits and risks of the procedure. The nurse's role is to witness informed consent and verify that it has occurred. (Option 2) NPO status is not required for paracentesis, which is often performed at the bedside or in an HCP's office using only a local anesthetic.

Which statement made by the client demonstrates a correct understanding of the home care of an ascending colostomy?

A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Colostomies can be performed on any part of the colon (ascending, transverse, descending, and sigmoid). Depending on the location of the colostomy, characteristics of the stool will vary, with the stool becoming more solid as it passes through the colon. Proper care of the stoma and pouch appliance that should be taught to the client or caregiver includes the following: Ensure sufficient fluid intake (at least 3,000 mL/day unless contraindicated) to prevent dehydration; identify times to increase fluid requirements (hot weather, increased perspiration, diarrhea) (Option 4). Identify and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, brussels sprouts) (Option 1). Empty the pouch when it becomes one-third full to prevent leaks due to increasing pouch weight (Option 2). (Option 3) Stool produced in the ascending and transverse colon is semiliquid, which eliminates the need for irrigation. Irrigation to promote a bowel regimen may be useful for descending or sigmoid colostomies as the stool is more formed.

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client?

Most bouts of diarrhea are self-limiting and last ≤48 hours. Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by a health care provider (HCP). Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication side effects, or laxative overuse. The HCP will need to assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea that may require further treatment (eg, Clostridium difficile). (Option 1) Instructions on eating bulk-forming foods may be helpful with diarrhea; however, this option does not seek to address the underlying problem causing the 4 days of diarrhea and fever. The client should see the HCP. (Option 2) Instructions on rest, fluids, and acetaminophen are helpful and would be the primary choice if the diarrhea had been occurring ≤48 hours without other symptoms. (Option 4) Loperamide (Imodium) is a synthetic opioid used as an antidiarrheal. It slows peristalsis and subsequently increases fluid absorption. It should not be used more than 2 days or if fever is present as retention of bacteria or toxins inside the colon can make the process worse and cause toxic megacolon.

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan?

Polycythemia vera (PV) is a chronic disorder of the bone marrow in which too many red blood cells, white cells, and platelets are produced. Clients with PV are at risk of developing blood clots due to increased blood volume and viscosity. Clients are instructed to elevate the legs and feet when sitting, wear support stockings, and report signs of thrombosis (eg, swelling and tenderness in the legs). Adequate fluid intake during exercise and hot weather is important to reduce fluid loss and decrease viscosity (Options 1, 3, and 5). (Option 2) Increasing intake of iron-containing foods and supplements can further increase hemoglobin production and is not recommended. Clients with PV need periodic phlebotomy to remove excess blood. (Option 4) Itching is a common and frustrating symptom of PV. Reducing water temperature, using starch baths, and patting the skin dry rather than rubbing vigorously are beneficial.

The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority?

A balloon tamponade tube (eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal (Option 2). (Option 1) If airway obstruction occurs, the nurse should first clear the airway and then ensure that the client is stable before contacting the health care provider. (Option 3) Low intermittent suction to the gastric lumen of a balloon tamponade tube is used to drain stomach contents. Increasing the suction would not be indicated if the tube has become displaced. (Option 4) If the balloon tamponade tube is displaced and obstructing the airway, changing the client's position will not help until the client's airway is cleared by removing the tube.

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. Which statement by the client shows a need for further instruction?

A barium enema, or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause subsequent peritonitis. Preprocedure instructions include: -Take a cathartic (eg, magnesium citrate, polyethylene glycol) to empty stool from the colon. -Follow a clear liquid diet the day before the procedure to aid in bowel preparation and to prevent dehydration; avoid red and purple liquids. -Do not eat or drink anything 8 hours before the test (Option 2). -Expect to be placed in various positions during the procedure. You may experience abdominal cramping and an urge to defecate (Option 3). -Postprocedure instructions include: Expect the passage of chalky, white stool until all barium contrast has been expelled (Option 1). Take a laxative (eg, magnesium hydroxide [Milk of Magnesia]) to assist in expelling the barium. Retained barium can lead to fecal impaction (Option 4). Drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent constipation.

The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required?

A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Clients with a descending or sigmoid colostomy drain stool that is more formed and similar to a normal bowel movement. Although less common, some clients choose to irrigate their colostomy in order to create a bowel regimen that allows them to wear a smaller pouch or a dressing over the stoma. When irrigated daily, the client gains increased control over the passage of stool. The procedure for bowel irrigation is as follows: Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on a hook or intravenous pole (Option 2) Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma (Option 3) Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes Clamp the tubing if cramping occurs, until it subsides (Option 4) Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet (Option 1) A cone-tip applicator is used to instill the irrigation solution into the stoma. An enema set should never be used to irrigate a colostomy. A cone-tip applicator is specifically made to avoid damage to the sensitive colostomy opening.

The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy. Which of the following nursing interventions are appropriate?

A gastroduodenostomy (Billroth I) involves removing the distal two-thirds of the stomach with anastomosis of the remaining stomach to the duodenum. Following partial gastrectomy, clients should remain NPO until bowel sounds return (Option 3). Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome (ie, rapid emptying of stomach contents into the small intestine). Postoperative clients are at risk for developing venous thromboembolism (VTE) due to reduced mobility levels and require VTE prophylaxis (eg, sequential compression devices, compression hose) (Option 1). Clients are also at risk for hypoventilation and respiratory compromise due to sedation, pain, and immobility. Encourage clients to turn, cough, and deep breathe while splinting the surgical site to prevent development of atelectasis (Option 2). (Option 4) In the postoperative period, the nurse should elevate the head of the bed to improve ventilation and reduce the risk of aspiration. Only clients who experience dumping syndrome should lay supine for a short period after eating. (Option 5) Clients may have a nasogastric tube postoperatively for gastric decompression. Clogged nasogastric tubesshould be reported to the surgeon. Attempting to manipulate or flush the device may disrupt the surgical site, causing hemorrhage or gastric perforation.

The nurse is preparing to administer medications to a client with an asthma exacerbation. Which prescription should the nurse confirm with the health care provider prior to administration? Laboratory results Day 1 Day 5 Hematocrit. 37% (0.37). 36% (0.36) Platelets 250,000/mm3 (250 × 109/L). 96,000/mm3 (96 × 109/L) White blood cells. 9,100/mm3 (9.1 × 109/L). 15,000/mm3 (15.0 × 109/L) Potassium. 3.8 mEq/L (3.8 mmol/L). 3.6 mEq/L (3.6 mmol/L)

A significant reduction in platelets after initiation of heparin or low-molecular-weight heparin (eg, enoxaparin[Lovenox]) therapy can indicate heparin-induced thrombocytopenia (HIT), a severe, potentially lethal complication. HIT is an immune reaction to heparin-based anticoagulants that causes a drastic decrease in platelet count (ie, ≤50% of pretreatment levels and/or platelet count <150,000/mm3 [150 × 109/L]) and a paradoxical increase in risk for arterial and venous thrombosis (eg, deep venous thrombosis, pulmonary embolism). The nurse should notify the health care provider immediately of decreased platelet levels and anticipate stopping enoxaparin therapy and initiating a nonheparin anticoagulant (eg, rivaroxaban, argatroban) (Option 2). (Option 1) Beta-2 adrenergic agonists (eg, albuterol, salmeterol) are medications used to dilate the airways. The nurse should clarify the prescription if hypokalemia or tachycardia, common adverse effects, are present. (Option 3) Methylprednisolone is a glucocorticoid medication used to reduce airway inflammation in asthma. Glucocorticoids can cause an expected, transient elevation in the white blood cell count during initiation of treatment. (Option 4) Potassium chloride is an electrolyte replacement drug used to prevent and treat hypokalemia (<3.5 mEq/L [3.5 mmol/L]). The nurse should clarify the prescription if hyperkalemia or kidney injury is present. This client has an additional risk for low potassium due to the continued use of albuterol.

A client on a medical-surgical unit is receiving heparin therapy. Platelet levels decreased from 230,000/mm3 (230 × 109/L) 2 days ago to 80,000/mm3 (80 × 109/L) today. Which nursing actions are appropriate?

A significant reduction in platelets after initiation of heparin therapy can indicate heparin-induced thrombocytopenia(HIT), a severe, potentially lethal complication. HIT is an immune reaction to heparin that causes a drastic decrease of ≥50% in platelets and a paradoxical increase in arterial and venous thrombosis. The nurse should notify the health care provider immediately and anticipate stopping heparin therapy and initiating a non-heparin anticoagulant (eg, warfarin, rivaroxaban, argatroban) (Options 2 and 3). Clients with HIT have increased risk for deep venous thrombosis (DVT) and pulmonary embolism. The nurse should perform a neurovascular assessment and report evidence of vascular clots (eg, DVT) to the health care provider. The nurse should also measure a full set of vital signs to assess for pulmonary embolism (eg, tachycardia, tachypnea, decreased oxygen saturation) (Option 4). When large changes are noted in laboratory values, it is important to draw repeat samples to confirm those values, as errors in sampling or specimen handling could result in inappropriate intervention (Option 1). (Option 5) Clients who are suspected of having HIT or who have a history of HIT should never receive heparin or low-molecular-weight heparin (eg, enoxaparin). Only non-heparin anticoagulants may be given.

The nurse is providing nutritional teaching for a client with a new ileostomy. Which foods should the nurse instruct the client to avoid?

An ileostomy is a surgically created opening (stoma) in the abdominal wall that connects the small intestine to the external abdomen. Stool from the small intestine bypasses the colon and exits through the ileostomy. Functions of the colon (eg, fluid and electrolyte absorption, vitamin K production) do not occur, resulting in liquid stool that drains into an external ostomy appliance attached to the skin. In the immediate postoperative period of an ileostomy, a low-residue diet (low-fiber) is prescribed to prevent obstruction of the narrow lumen of the small intestine and stoma (1-in [2.54-cm] diameter or less). After the ileostomy heals, the client reintroduces fibrous foods one at a time. The client is instructed to thoroughly chew food and monitor for changes in stool output. Foods to be avoided include: -High fiber: popcorn, coconut, brown rice, multigrain bread (Options 3 and 4) -Stringy vegetables: celery, broccoli, asparagus (Option 2) -Seeds or pits: strawberries, raspberries, olives -Edible peels: apple slices, cucumber, dried fruit (Option 1) After an ileostomy, a client may consume fruits and vegetables that are pitted, peeled, and/or cooked (eg, peaches, bananas, potatoes). (Option 5) Low-fiber carbohydrate options include white rice, refined grains, and pasta.

The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first?

Appendicitis is inflammation of the appendix and often results from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. When prioritizing care of the client with appendicitis, the nurse should utilize the ABCs (ie, airway, breathing, circulation). Fluid resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed at preventing circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status (Option 3). (Option 1) Pain medications may be administered to promote comfort, but should be administered via IV route to maintain NPO status in case of emergency surgery. However, circulation takes priority over pain medication. (Options 2 and 4) Blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse should prioritize circulatory status over obtaining laboratory specimens.

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective?

Ascites is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis. Ascitic fluid increases abdominal pressure, resulting in weight gain, abdominal distension and discomfort, and shortness of breath. Paracentesis (ie, needle insertion through the abdomen into the peritoneum to remove ascitic fluid) is often performed to reduce symptoms of ascites. However, clients undergoing paracentesis must be monitored closely for hypotension as changes in abdominal pressure often result in systemic vasodilation. Clients may receive IV albumin (a colloid) after paracentesis, which increases intravascular oncotic pressure resulting in increased intravascular fluid volume. Albumin administration prevents hypotension and tachycardia by mitigating hemodynamic changes associated with paracentesis (Option 4). (Options 1 and 3) Decreased abdominal circumference and improved respiratory effort occur in clients with ascites after ascitic fluid is removed via paracentesis. Albumin does not directly reduce ascitic fluid volume. (Option 2) Asterixis (ie, flapping hand tremors during arm extension) occurs due to elevated blood ammonia levels. Lactulose is commonly used to treat asterixis as it promotes ammonia excretion. Albumin does not affect ammonia excretion.

The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel?

Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent (every 5-15 seconds), high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4 quadrants. Cardiovascular bruits (swishing, humming, buzzing) are rarely benign and usually indicate arterial narrowing or dilation. Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for the first 24-48 hours, resulting in absent bowel sounds (Option 1). For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalsis will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds. (Option 2) Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction. (Option 3) High-pitched, gurgling sounds signify normal bowel sounds and are unlikely to be heard immediately following abdominal surgery. (Option 4) A swishing, humming, or buzzing sound (bruit) may be cardiovascular in origin; a bruit indicates turbulent blood flow as with artery dilation (aneurysm) or narrowing (obstruction). A bruit can best be auscultated with the bell of the stethoscope.

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination?

Cardinal symptoms of acute cholecystitis from cholelithiasis include pain in the RUQ with referred pain to the right shoulder and scapula (Option 5). Clients often report fatty food ingestion 1-3 hours before the initial onset of pain. Associated symptoms include low-grade fever, chills, nausea, vomiting, and anorexia (Option 3). During an acute attack, inflammation of the mucous lining and wall of the gallbladder occurs as a result of gallstone(s) obstruction of the cystic bile duct. The inflammation and increased pressure in the gallbladder from the blocked bile duct results in Murphy's sign; palpation over the RUQ causes pain and inability to take a deep breath. Laboratory results show leukocytosis. (Option 1) Flank pain radiating to the groin is seen with renal colic (ureteral stones). (Option 2) It is not dietary protein but food with significant fat content (cheese, avocado, fried foods, hamburger) that signals the gallbladder to contract, emptying bile into the duodenum to help digestion. Gallstones normally harmlessly floating around the gallbladder are squeezed into the bile duct, causing the pain of biliary colic. Gallstones stuck further down the bile duct may become colonized by a bacterial infection (choledocholithiasis). (Option 4) Initial onset of pain at the umbilicus is seen with acute appendicitis.

The nurse is reviewing medical histories with several clients during a community health screening event. Which of the following client statements indicate a risk factor for cervical cancer?

Cervical cancer is a malignancy of the cervix (a portion of the uterus) that normally occurs near the meeting point of the vaginal and uterine epithelia (the transformation zone), located in the endocervical canal. Uterine epithelial cells in this area are rapidly and constantly replaced with squamous cells (ie, squamous metaplasia), a natural process that also increases the risk for abnormal cell changes and cancer. The most important risk factor for cervical cancer is persistent human papillomavirus (HPV) infection, a common, transient, and often asymptomatic sexually transmitted infection (STI) that can be identified in almost all clients with cervical cancer (Option 5). Most other risk factors are related to acquiring, clearing, or increasing the cancer-causing effects of HPV infection, including: Having multiple sexual partners (ie, >1 lifetime partner), which increases the chance of HPV exposure (Option 1) Smoking tobacco, which is believed to promote cell mutation and increase the likelihood of HPV infection (Option 2) Being infected with other STIs (eg, gonorrhea, chlamydia), which increases the likelihood of HPV infection (Option 4) (Option 3) Condoms help to prevent HPV transmission between partners, and not taking oral contraceptives is associated with a decreased risk for cervical cancer.

The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant. Based on the client's electronic health record, the nurse anticipates which assessment findings?

Cirrhosis of the liver occurs when chronic liver disease (eg, hepatitis C infection) causes scar tissue and nodules, which can decrease liver function and lead to liver failure. Clients with end-stage liver disease may experience exacerbations requiring hospitalization and acute intervention. Numerous laboratory abnormalities occur in the setting of liver failure and correlate with assessment findings (eg, high serum ammonia resulting in hepatic encephalopathy) (Options 1, 2, 4, and 5). (Option 3) Lactulose, an osmotic laxative, decreases serum ammonia levels by causing ammonia to be excreted through stool. The desired therapeutic effect is the production of 2 or 3 soft bowel movements each day; therefore, clients receiving lactulose should not exhibit constipation.

The nurse is teaching a client with newly diagnosed lactase deficiency about dietary management. Which statements by the client indicate a correct understanding of this condition?

Clients with lactase deficiency (lactose intolerance) experience varying degrees of gastrointestinal symptoms after ingesting milk products, including flatulence, diarrhea, bloating, and cramping. This is due to a deficiency of the enzyme lactase, which is required for digestion of lactose. Treatment includes restricting lactose-containing foods in the diet. These clients may also take lactase enzyme replacements (eg, Lactaid) to decrease symptoms (Option 4). Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified milk (Option 2). Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual tolerance (Option 3). Some dairy products, including aged cheeses and live-culture yogurts, contain little to no lactose and can be tolerated by most clients with lactase deficiency (Option 1). (Option 5) Lactase deficiency is not an immune reaction (allergy) to milk products. Rather, the gastrointestinal symptoms are due to a deficiency of the enzyme lactase and the resultant inability to digest lactose.

A healthy 50-year-old client asks the nurse, "What must I do in preparation for my screening colonoscopy?" Which statements by the nurse correctly answer the client's question?

Colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no stool left for better visualization during the procedure. These instructions include: Clear liquid diet the day before Nothing by mouth 8-12 hours prior to the examination The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene glycol (GoLYTELY) the day before the test. The type of prep depends on the health care provider's preference and client health status. (Option 2) Healthy clients screened for colon disease do not require antibiotics prior to the procedure. (Option 3) The instructions prior to a nuclear gastric emptying scan include teaching the client to avoid smoking the day of the examination as delay of gastric emptying occurs with tobacco use. Smoking cessation per se has no role in colonoscopy, but it is good for general health.

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer?

Colorectal cancer occurs most often in adults over age 50. Risk factors include history of colon polyps; family history of colorectal cancer; inflammatory bowel disease (eg, Crohn disease, ulcerative colitis); and history of other cancers (eg, gastric, ovarian). Symptoms of colorectal cancer may include: -Blood in the stool (eg, positive occult blood, melena) from fragile, bleeding polyps or tumors (Option 2) -Abdominal discomfort and/or mass (not common) (Option 1) -Anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion (Option 4) -Change in bowel habits (eg, diarrhea, constipation) due to obstruction by polyps or tumors (Option 3) -Unexplained weight loss due to impaired nutrition from altered intestinal absorption (Option 5) Colorectal cancer often goes unnoticed, as many of the symptoms are painless and nonspecific. Clients should be assessed for these symptoms and receive regular routine colorectal cancer screening tests (eg, occult blood test every year, colonoscopy every 10 years).

The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia?

Conditions that increase intraabdominal pressure (eg, pregnancy, obesity, ascites, tumors, heavy lifting) and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm, causing a hiatal hernia. A sliding hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm. A paraesophageal hernia (rolling hernia) occurs when the gastroesophageal junction remains in place but a portion of upper stomach folds up along the esophagus and forms a pocket. Paraesophageal hernias are a medical emergency. Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated with gastroesophageal reflux disease (GERD), including heartburn, dysphagia, and pain caused by increased intraabdominal pressure or supine positioning. Interventions to reduce herniation include the following: -Diet modification—avoid high-fat foods and those that decrease lower esophageal sphincter pressure (eg, chocolate, peppermint, tomatoes, caffeine). -Eat small, frequent meals, and decrease fluid intake during meals to prevent gastric distension. -Avoid consumption of meals close to bedtime and nocturnal eating (Option 3). -Lifestyle changes—smoking cessation, weight loss (Option 2). -Avoid lifting or straining (Option 5). -Elevate the head of the bed to approximately 30 degrees—this can be done at home using pillows or 4 - 6 inch blocks under the bed (Option 1). (Option 4) Wearing a girdle or tight clothes increases intraabdominal pressure and should be avoided.

A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions?

Continuous suction can be applied to decompress the stomach if a double lumen Salem sump tube is in place. The larger lumen is attached to suction and the smaller lumen (within the larger one) is open to the atmosphere. Checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous suction for decompression and is not being used to administer enteral feeding (Option 1). The air vent (blue pigtail) must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa. If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level of the client's stomach to prevent reflux (Option 3). General interventions to maintain gastric suction using a Salem sump tube include: -Place the client in semi-Fowler's position to help keep the tube from lying against the stomach wall; this is done to help prevent gastric reflux (Option 2). -Provide mouth care every 4 hours as this helps to maintain moisture of oral mucosa and promote client comfort (Option 4). -Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds (Option 5). Inspect the drainage system for patency (eg, tubing kink or blockage).

Which client is at greatest risk for pulmonary embolism?

Death from pulmonary embolism is often attributed to a missed diagnosis. Early identification of risk factors (eg, venous stasis, hypercoagulability of blood, endothelial damage) can have a positive effect on client outcome. This postoperative client is at greatest risk due to the presence of the following 4 risk factors: -Abdominal cesarean section surgery (endothelial damage) -Engorged pelvic vessels from pregnancy (venous stasis, hypercoagulability of blood) -Inactivity/immobility ≥6 hours related to positioning during surgery and the immediate postoperative period and epidural anesthesia (venous stasis) -Postpartum state (hypercoagulability of blood) (Option 2) In atrial fibrillation, stasis and turbulence of blood increases risk of thrombus formation. Once mobilized, emboli can get trapped in blood vessels causing ischemia. Smaller vasculature and increased blood flow in the brain increases the probability of a stroke, rather than PE. This client has 1 risk factor and is not at greatest risk for PE. (Option 3) The presence of a subdural hematoma does not pose a significant risk for PE unless the client has been immobile. Many clients with subdural hematomas are asymptomatic and walking. This client is not at greatest risk for PE. (Option 4) Any acute medical illness (eg, pneumonia) can predispose a client to PE from inflammation and the client's relative immobility. However, this risk is lower than the risk for PE from major surgery.

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan?

Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) improves stool elimination, which helps prevent constipation and decreases the risk of colorectal cancer (Options 1 and 5). Fiber-rich foods tend to have a low glycemic load (less sugar per serving) and are nutrient dense, yet they have lower caloric density. Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss (Options 2 and 3). Fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke (Option 4).

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider?

Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop. When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis). Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and intestinal perforationresulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound tenderness). The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum. Peritonitis is a potentially lethal complication and should be reported immediately. (Option 2) Clients with acute diverticulitis can bleed. Usually this bleeding is quite obvious, often with a large amount of bright red blood seen in the stool. This client's mild anemia is nonspecific and should not be given reporting priority over the peritoneal signs. (Option 3) This indicates fetal position and could be due to pain. Clients with peritonitis are expected to lie still as any movement worsens the pain. Peritonitis takes priority over the expected pain in diverticulitis. (Option 4) Leukocytosis is expected with acute diverticulitis. However this client's white blood cell count is only minimally elevated (upper limit of normal is 11,000/mm3 [11.0 x 109/L]) and is not a priority over possible peritoneal signs.

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes?

Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine (diverticula). Diverticulosis is characterized by the presence of these protrusions; the client is asymptomatic and may not even be aware of the condition. Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool. The etiology of diverticular disease has been linked to chronic constipation, a major cause of excess intracolonic pressure. Preventing constipation may help reduce the risk of diverticula forming and becoming inflamed. Measures to prevent constipation include a diet high in fiber (whole grains, fruits, vegetables), daily intake of at least 8 glasses of water or other fluids, and exercise. A fiber supplement such as psyllium or bran may be advised. In the past, clients have been taught to avoid consuming seeds, nuts, and popcorn; however, current evidence does not indicate that avoidance of these foods will prevent an episode of diverticulitis. (Option 3) A low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes. (Option 5) Increased consumption of red meat and other high-fat foods can increase the risk of diverticulitis.

The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse's initial action?

Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment. (Options 1 and 2) The cause of anemia must be determined before recommendations can be provided for iron deficiency. There are many causes of anemia (including pernicious anemia) in older adults that involve deficiencies in vitamin B12, not iron. (Option 4) Waiting for 6 months will delay care.

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention?

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threateningcomplication after an ERCP. Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (eg, amylase, lipase) (Option 3). (Option 1) Abdominal cramps can occur after a colonoscopy due to air inflation during the procedure. (Option 2) The barium contrast solution used during the procedure may make the client's stool white for up to 3 days. The nurse should encourage fluids, if appropriate, to assist in expulsion of the contrast medium. (Option 4) Copious, bile-colored (greenish-brown) drainage is expected in a client with a small bowel obstruction. The nurse should watch for signs and symptoms of electrolyte imbalances (hypokalemia), dehydration, and metabolic alkalosis.

The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer?

Esophageal cancer is a rare, rapidly growing malignancy of the esophageal lining with a low 5-year survival rate. Squamous cell carcinoma usually develops in the upper part of the esophagus, whereas adenocarcinoma usually develops in the lower part. Major risk factors include smoking (eg, cigarettes, pipe, cigars) and excessive alcohol consumption (ie, approximately >15 drinks/week for men, >8 drinks/week for women) (Options 1 and 3). Barrett esophagus is also a significant risk factor for esophageal cancer; this condition occurs when the distal portion of the esophagus develops precancerous changes. Obesity (which allows stomach acid to flow upward into the esophagus due to increased abdominal pressure) and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett esophagus; they are both closely linked with esophageal cancer (Options 2 and 4). (Option 5) Consumption of salty foods is not associated with an increased risk of esophageal cancer but increases the risk of gastric cancer. Dietary factors that may increase a client's risk of esophageal cancer include high intake of nitrosamine-containing foods (eg, pickled foods, beer), frequent ingestion of extremely hot beverages (thermal injury), and deficient intake of fruits and vegetables.

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms?

Hematocrit (Hct) is the percentage of red blood cells (RBCs) in a volume of whole blood. Hct and hemoglobin (Hgb) values are related (approximately 3 x Hgb = Hct); when one value is decreased, the other is also. This client likely has hemoglobin of 7 g/dL (70 g/L) (normal, 13.2-17.3 g/dL [132-173 g/L] for males and 11.7-15.5 g/dL [117-155 g/L] for females). Hgb is a component of the RBC that carries oxygen to the body's tissues. A decrease in Hgb decreases oxygen-carrying capacity and transport to tissues. RBCs may be 100% saturated with oxygen at rest, but desaturation may occur with increased activity and oxygen demand in the presence of decreased Hct and Hgb. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia. (Option 1) Brain natriuretic peptide (BNP) >100 pg/mL (100 pmol/L) is considered elevated and indicates ventricular stretch (heart failure) as the cause of the dyspnea. This client has normal BNP levels, making heart failure an unlikely cause. (Option 3) The leukocyte count is decreased (normal, 4,000-11,000/mm3 [4.0-11.0 x 109/L]). Leukocytes play a role in protecting the body from disease. (Option 4) The platelet count is decreased (normal, 150,000-400,000/mm3 [150-400 x 109/L]). Platelets play a role in blood clotting.

The nurse is providing postoperative care to a client returning from a hemorrhoidectomy. Which action is the priority for the nurse to perform?

Hemorrhoids (distended, inflamed veins located in the anus or lower rectum) are caused by increased anorectal pressure(straining to defecate, constipation). Clients may experience symptoms such as rectal bleeding, pain, pruritus, and prolapse. Although removal of hemorrhoids (hemorrhoidectomy) is a minor procedure, the pain associated with it is due to spasms of the anal sphincter and is severe. Nursing management for the post-hemorrhoidectomy client includes the following: -Pain relief: Initially, pain is managed with pain medications, including nonsteroidal anti-inflammatory drugs (eg, ibuprofen) and/or acetaminophen; opioids can be prescribed initially but may worsen constipation. Beginning 1-2 days postoperatively, warm sitz baths are used as a means to relieve pain. Clients often dread their first bowel movement due to severe pain with defecation. Therefore, pain must be appropriately controlled to prevent further constipation (Option 2). -Preventing constipation: Encourage a high-fiber diet and adequate fluid intake (at least 1500 mL/day). Administer a stool softener such as docusate (Colace) as prescribed. An oil-retention enema may be used if constipation persists for 2-3 days (Option 1). (Option 3) Postoperatively, the health care provider may pack the rectum and apply a T-binder to hold the packing in place. The dressing is usually removed 1-2 days postoperatively unless excess soaking is noted before. (Option 4) Warm sitz baths are used beginning 1-2 days postoperatively, 2-3 times daily (15-20 minutes each) for 7-10 days to provide pain relief, decrease swelling, and cleanse the rectal area.

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy?

Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. (Option 3) Spider angiomas (eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. (Option 4) Jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy. (Option 5) Amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferase and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis.

The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication?

Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood-brain barrier, leading to neurological dysfunction (Option 1). Lactulose is the most common treatment for hepatic encephalopathy. Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an acidic environment and a hyperosmotic effect (laxative). In this acidic environment, ammonia (NH3) is converted to ammonium (NH4+) and excreted rapidly. Lactulose can be given orally with water, juice, or milk (to improve flavor) or it can be administered via enema (Option 4). For faster results, it can be administered on an empty stomach (Option 2). The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached (improved mental status, decreased ammonia levels) (Option 3). The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia.

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client?

Lymphedema is the accumulation of lymph fluid in the soft tissue. It can occur as a result of lymph node removal or radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid can accumulate in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor function may be impaired. The presence of lymphedema increases the client's risk for infection or injury of the affected limb. Interventions to manage lymphedema include: -Decongestive therapy (massage technique to mobilize fluid) -Compression sleeves or intermittent pneumatic compression sleeve (Option 5) -Compression sleeves are graduated with increased distal pressure and less proximal pressure.Clothing should also be less constrictive at the proximal arm and over the chest. -Elevation of arm above the heart (Option 3) -Isometric exercises (Option 4) -Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure measurements, and injections (eg, vaccinations) on the affected limb (Option 2) -Injury prevention (limb less sensitive to temperature changes)Infection prevention (limb more prone to infection through skin breaks) (Option 1) Clients often learn massage techniques (ie, decongestive therapy) from physical therapists to increase lymphatic drainage and promote circulation of the extremity.

The nurse is obtaining a client's health history during a routine physical and wellness examination. Which of the following statements by the client should cause the nurse to suspect potential Hodgkin lymphoma?

Lymphoma is a form of cancer that begins in the body's lymphatic system (eg, lymph nodes, spleen) and is characterized by abnormal growth of lymphocytes. It is usually classified within two major subtypes, Hodgkin lymphoma and non-Hodgkin lymphoma (NHL), and is further identified by numerous subcategories. To be diagnosed with Hodgkin lymphoma, malignant Reed-Sternberg cells must be found in the lymphatic tissue. Furthermore, Hodgkin lymphoma tends to follow a predictable path of metastasis, whereas NHL tends to be more widely disseminated. The most common clinical manifestation of any form of lymphoma is the presence of at least one painless, enlarged lymph node, often in the neck, underarm, or groin (Option 2). Clients may also present with or develop fever; significant, unexplainable, and/or unintentional weight loss (>10% of body weight); and/or drenching night sweats (ie, "B symptoms"); which typically associate with a poor prognosis (Options 1, 3, and 5). Additional indications are nonspecific (eg, itching, fatigue), although some clients are asymptomatic at the time of diagnosis (Option 4).

A 78-year-old client recovering from a hip fracture tells the home health nurse, "I haven't had much of an appetite lately and have been really tired. I'm worried I'm not eating enough." Which question is the priority for the nurse to ask?

Malnutrition occurs when there is insufficient nutrient intake to meet body needs and relates to multiple factors (eg, poor diet, chronic illness, physical or cognitive impairments). Malnutrition may impair critical physiologic processes (eg, organ and immune system function, wound healing) and can have rapid and potentially lethal implications. Therefore, nurses should frequently assess clients for malnutrition, particularly those at increased risk (eg, advanced age, altered functional status). Assessing for malnutrition involves collecting dietary data (eg, 24-hour diet recall), laboratory values (eg, albumin or prealbumin), physical measurements (eg, BMI), and history of recent weight loss (Option 3). Reports of weight loss, especially unintentional, are critical findings often indicative of malnutrition. In addition, weight loss of ≥5% in 1 month or ≥10% in 6 months may indicate serious conditions (eg, cancer, tuberculosis, failure to thrive). (Option 1) Impaired functional status may contribute to a client's malnutrition. The nurse should prioritize assessing for the presence of malnutrition before assessment of contributing factors. (Option 2) Assessment of psychologic factors (eg, depression, loneliness) is important to determine possible reasons for malnutrition but should be performed only after determining the extent of malnutrition. (Option 4) Meal frequency, eating habits, and recent diet changes are possible contributing factors leading to malnutrition that should be assessed after determining malnutrition risk.

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy. The nurse teaches the client to use which of the following oral hygiene practices?

Oral mucositis, inflammation or ulceration of the oral mucosa, results from chemotherapy or radiation therapy. Oral hygiene practices that minimize oral mucositis and promote comfort include the following: -Cleansing the mouth with normal saline after meals and at bedtime to promote oral health -Use of a soft-bristle toothbrush to decrease gum irritation -Application of prescribed viscous lidocaine HCl (Xylocaine) to alleviate oral pain Use of water-soluble lubricating agents to moisten mouth tissues that may become dry due to therapy -Avoidance of hot liquids and spicy/acidic foods, which can cause oral discomfort (Option 5) Clients with mucositis should avoid antiseptic mouthwashes with alcohol as they are irritating to mucous membranes. (Option 6) Administration of palifermin (Kepivance), a recombinant human keratinocyte growth factor, prevents oral mucositis in clients diagnosed with hematologic malignancies. However, it does not help with pain. Viscous lidocaine HCl (Xylocaine) alleviates the oral pain caused by mucositis.

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery. During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm. What action should the nurse take?

Ordinarily, lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial, small (0.5-1 cm), mobile, firm, and nontender is considered a normal finding. It could easily be explained by the relatively recent mastectomy (trauma) with resulting inflammation and lymph flow interference. A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to inflammation but hard or fixed nodes could indicate malignancy. (Option 1) A biopsy is performed for an abnormal lymph node finding that could suggest malignancy. (Option 2) The swelling is caused by inadequate lymph drainage or inflammation, not localized edema. Ice is not recommended for this normal finding. (Option 4) There is no indication of lymphangiitis requiring antibiotics. This may produce a red streak with induration following the course of the lymphatic collecting duct. Infected skin lesions may also be present.

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client's abdomen by pressing one hand firmly into the abdominal wall. The client experiences pain when the nurse quickly withdraws the hand. The client's most recent blood glucose level is 210 mg/dL (11.65 mmol/L). What is the priority action by the nurse?

Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent. Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity. The nurse should collect peritoneal effluent from the drainage bag for culture and sensitivity (Option 1). Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously. (Option 2) The client's chills and rebound tenderness are signs of infection that require further assessment. Dialysate is typically warmed to body temperature before instillation to prevent abdominal discomfort and increase urea clearance through vessel dilation. Dry heating with a heating cabinet or incubator rather than a microwave is recommended to reduce the danger of burning the peritoneum. The dwell time is based on the prescribed dialysis method and should not be extended without a prescription. (Option 3) High Fowler's position can help reduce shortness of breath if the client has volume overload, but it may worsen abdominal pain. (Option 4) Glucose (dextrose) is the osmotic agent in dialysate. Therefore, glucose levels must be monitored closely, particularly in clients with diabetes. However, a glucose level of 210 mg/dL (11.65 mmol/L) does not necessitate IV administration of regular insulin. Regular insulin can be added to the dialysate before the solution is instilled, or it can be administered subcutaneously to control glucose levels.

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?

Postoperative nursing care after a laparoscopic cholecystectomy focuses on prevention of complications. Carbon dioxide (CO2) is used to inflate and expand the abdominal cavity during laparoscopic procedures to allow insertion of surgical instruments and better visualization of the abdominal organs. CO2 can irritate the phrenic nerve and diaphragm, causing shallow breathing and referred pain to the right shoulder. The nurse should assist the client with early ambulation and deep breathing to facilitate dissipation of the CO2 used during surgery (Option 2). Early ambulation not only improves breathing but also decreases the risk of thromboembolism and stimulates peristalsis. (Option 1) Anti-embolism stockings help prevent the development of deep vein thrombosis, but early ambulation is more effective at thromboembolism prevention and is therefore the priority intervention. (Option 3) Stool softeners may prevent postoperative constipation caused by surgical anesthetics and opioids, which contribute to decreased peristalsis. However, early ambulation promotes bowel motility and reduces constipation. (Option 4) After laparoscopic cholecystectomy, the client should maintain a clear liquid diet until bowel sounds return. After obtaining an order from the health care provider, the nurse should advance to a low-fat diet and educate the client on weight reduction and maintaining a low-fat diet.

The community health nurse provides an education program about risk factors for prostate cancer. Which of the following statements by program attendees indicate that teaching has been effective?

Prostate cancer is a slow-growing and predictable malignancy. If not treated, it can metastasize to nearby lymph nodes, liver, lungs, and bone. Clients should discuss the risks and benefits of screening for prostate cancer (eg, checking serum prostate-specific antigen) with their health care provider. Certain factors place clients at greater risk, and early screening can detect prostate cancer before it becomes invasive (metastasizes). The nurse should educate clients about risk factors. Nonmodifiable risk factors (eg, those the client cannot control) include African American ethnicity, having a first-degree relative with prostate cancer, and increasing age (>50) (Options 1, 4, and 5). Clients can lower the risk for prostate cancer by avoiding modifiable (ie, those the client can control) risk factors, which include: -Diet high in red meat, animal fat, high-fat dairy products, and refined carbohydrates (Option 2) -Low fiber intake -Obesity (Option 3) Long-term use of NSAIDs (eg, aspirin, ibuprofen) can be a protective factor against certain types of cancer (eg, colorectal, prostate). However, before regularly taking NSAIDs, clients should speak with their health care provider because NSAIDs can increase the risk for adverse effects (eg, cardiovascular disease, bleeding).

A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.1 kg) but weighed 150 lb (68 kg) 3 months prior to admission. Which foods would be the best for this client?

Reduced appetite and significant, unintentional weight loss are included in the diagnostic criteria for unipolar major depression (major depressive disorder). A 35-lb (15.9-kg) weight loss within 3 months is a 23% change in this client's usual body weight and is considered severe weight loss. The client needs a diet high in calories and protein to promote adequate nutrition and weight gain. In addition, the client has a diagnosis of depression and may have a low energy level; providing foods that are easier to chew and swallow may be better choices for promoting intake. Foods that are protein and/or calorie dense include: -Whole milk and dairy products (eg, milkshakes), fruit smoothies -Granola, muffins, biscuits -Potatoes with sour cream and butter -Meat, fish, eggs, dried beans, almond butter -Pasta/rice dishes with cream sauce (Option 1) The client is taking phenelzine (Nardil), which is a monoamine oxidase inhibitor (MAOI). Foods high in tyramine (eg, aged cheese, yogurt, cured meats, smoked meat or fish, fermented foods, broad beans, beer, red wine, chocolate, avocados) need to be restricted to reduce the risk of a hypertensive crisis. (Option 2) This choice is an excellent protein option but is low in calories. The client needs foods high in calories and protein. (Option 4) This choice provides calories but is low in protein and high in tyramine. The client needs to consume foods that are high in calories and protein but low in tyramine.

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations?

Small-bowel obstruction can have mechanical or non-mechanical causes. Mechanical obstruction is commonly caused by obstruction of the bowel resulting from surgical adhesions, hernias, intussusception, or tumors. Paralytic ileus, a non-mechanical obstruction, may occur after abdominal surgery or narcotic use. When a small-bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid onset of nausea and vomiting (Option 4), colicky intermittent abdominal pain (Option 3), and abdominal distension (Option 1). The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise, bowel ischemia, or perforation. Nursing management of an obstruction includes placing the client on NPO status, inserting a nasogastric tube, administering prescribed IV fluids, and instituting pain control measures. (Option 2) Symptoms of a large-bowel obstruction differ slightly from small-bowel obstruction and include gradual onset of symptoms, cramping abdominal pain, abdominal distension, absolute constipation, and lack of flatus. Constipation and decreased flatus resulting from small-bowel obstruction would occur later, as the stool and gas in the large colon would be expelled for a few days. (Option 5) Pain during defecation usually indicates a rectal problem such as inflammation, anal fissure, or thrombosed hemorrhoids.

The nurse is counseling a client with obesity who is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes?

Sugary beverages, such as regular soft drinks, are key contributors to the excess consumption of calories and the obesityepidemic. Individuals who are attempting to lose weight should consume beverages with nutritional value and little-to-no caloric value, including: Water Club soda (flavored or unflavored) (Option 2) Unsweetened tea and/or coffee (Option 5) Fresh vegetable juice (Option 3) Nonfat or low-fat milk (in limited amounts) A 12-oz (355-mL) serving in a typical can of regular cola-type beverage contains around 140 calories (kcal). For this client, the consumption of 5 cola beverages daily is contributing 255,500 kcal per year and accounts for 73 lb (33.2 kg) (3500 kcal/lb). This client could lose 73 lb (33.2 kg) in a year simply by substituting zero-calorie beverages for cola.

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client?

Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. These strategies include: NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces). (Option 4) The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's) to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better. (Option 5) NPO status is maintained to inhibit stimulation of pancreatic enzymes.

The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis?

The appendix is a blind pouch located at the junction of the ileum of the small intestine and the beginning of the large intestine (cecum). When infected or obstructed (foreign body, fecal material, tumor, lymph tissue), the appendix becomes inflamed, causing acute appendicitis. Signs and symptoms of acute appendicitis include the following: Pain: Continuous; begins in the periumbilical region and then moves to the right lower quadrant centering at McBurney's point (one-third of the distance from the right anterior superior iliac spine to the umbilicus) (Option 3) Gastrointestinal symptoms: Anorexia, nausea, and vomiting Rebound tenderness and guarding Clients with acute appendicitis attempt to decrease pain by preventing increased intraabdominal pressure (eg, avoiding coughing, sneezing, deep inhalation) and lying still with the right leg flexed. (Option 1) Burning pain in the upper abdomen can be due to gastric or duodenal ulcers. If the ulcers are located posteriorly, the client may experience back pain. (Option 2) Pain in the left lower quadrant is associated with diverticulitis (often in the sigmoid colon). Other signs and symptoms include a palpable, tender abdominal mass and systemic symptoms of infection (fever, increased C-reactive protein, and leukocytosis with a left shift). (Option 4) Pain and tenderness in the epigastric or right upper quadrant of the abdomen that is referred to the right scapula is associated with acute cholecystitis. Clients may also experience indigestion, nausea, vomiting, restlessness, and diaphoresis.

The nurse is assisting with a colorectal cancer screening using the guaiac fecal occult blood test. Place the steps for completing this test in the correct sequence

The guaiac fecal occult blood test is used to assess for microscopic blood in the stool as a screening tool for colorectal cancer. The steps for collecting a sample include: 1. Assess for recent ingestion (within last 3 days) of red meat or medications (eg, vitamin C, aspirin, anticoagulants, iron, ibuprofen, corticosteroids) that may interfere and produce false test results. 2. Obtain supplies (Hemoccult test paper, wooden applicator, Hemoccult developer), wash hands, and apply nonsterile gloves (Option 2). 3. Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. Collect from 2 different areas of the specimen as some portions of the stool may not contain microscopic blood (Option 4). 4. Close the slide cover and allow the stool specimen to dry for 3-5 minutes. 5. Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide (Option 3). 6. Assess the color of the Hemoccult slide paper within 30-60 seconds. A positive guaiac result will turn the test paper blue, indicating presence of microscopic blood in the stool (Option 5). 7. Dispose of used gloves and the wooden applicator and perform hand hygiene. 8. Document the results (Option 1).

A hospitalized client is receiving chemotherapy. Based on today's blood laboratory results, what action should the nurse take? Laboratory results White blood cell count1,400/mm3 (1.4x109/L) Absolute neutrophil count500/mm3 (0.5x109/L) Hemoglobin10.5 g/dL (105 g/L) Platelets150,000/mm3 (150x109/L) Serum potassium3.4 mEq/L (3.4 mmol/L)

The normal range for a WBC count is 4,000-11,000/mm3 (4.0-11.0×109/L). Clients with neutropenia (a reduction in WBCs) are predisposed to infection. The absolute neutrophil count (ANC) is determined by multiplying the total WBC count by the percentage of neutrophils. Neutropenia is an ANC below 1,000/mm3 (1.0×109/L). An ANC below 500/mm3 (0.5×109/L) is defined as severe neutropenia and is a critical emergency. This client's neutropenia is probably a result of bone marrow suppression from the chemotherapy. The client needs reverse or protective isolation from organisms that people or objects may have that the client lacks resistance to. A hospitalized client needs to be in a private room, and the room may need to be equipped with HEPA (high-efficiency particulate air) filtration (or positive pressure air flow). Until the room can be readied, the client should be protected with a mask and separated from infectious clients. Additional neutropenic precautions include avoiding raw fruits/vegetables, standing water, and undercooked meat. In addition, no infectious health care providers (eg, with colds) should care for the client. (Option 1) Thrombocytopenia (low platelets) can result from bone marrow suppression caused by chemotherapy. This client's platelets are at the low end of the normal range (150,000-400,000/mm3 [150-400× 109/L]). Spontaneous or surgical bleeding from thrombocytopenia rarely occurs with a platelet count of >50,000/mm3 (50 × 109/L). (Option 2) This client's potassium level is slightly low (normal 3.5-5.0 mEq/L [3.5-5.0 mmol/L]). Low potassium, if it affects the cardiac tracing, causes flattened T waves. Peaked or tented T waves on a cardiac tracing are related to hyperkalemia. (Option 3) Epoetin alfa (human recombinant erythropoietin) is a hematopoietic growth factor. The erythropoietin is produced in the kidney and stimulates bone marrow production of red blood cells (RBCs), a process called erythropoiesis. Epoetin alfa is used to stimulate RBC production but is not typically prescribed unless the client has symptomatic anemia with hemoglobin of <10 g/dL (100 g/L).

The oncology nurse is caring for a client with tumor lysis syndrome. Which prescription should the nurse question?

Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in the release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: -Hyperkalemia (>5.0 mEq/L [5.0 mmol/L]) that can cause lethal dysrhythmias -Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) that can overwhelm the kidneys and cause hyperuricemia and acute kidney injury (AKI) from uric acid crystal formation -Hyperphosphatemia (>4.4 mg/dL [1.42 mmol/L]) that can cause AKI and dysrhythmias -Hypocalcemia (<8.6 mg/dL [2.15 mmol/L]) that can cause tetany and cardiac dysrhythmias Potassium-sparing medications (eg, spironolactone) can worsen hyperkalemia (Option 4). Loop or osmotic diuretics may be prescribed to increase urine output and lower serum potassium. Sodium polystyrene sulfonate (Kayexalate) also helps to reduce potassium. (Options 1 and 2) Hypouricemic agents (eg, allopurinol) prevent the formation of uric acid, and aggressive fluid hydration (eg, IV normal saline) flushes out the kidneys to avoid the accumulation of toxins. Hydration therapy also dilutes serum potassium, lowering the risk for lethal dysrhythmias. (Option 3) Health care providers often prescribe mealtime phosphate binders (eg, sevelamer, lanthanum carbonate, calcium acetate) to prevent absorption of additional nutritional phosphorus.

The nurse cares for a client with ulcerative colitis who is having abdominal pain and ≥10 bloody stools per day. Which of the following interventions should be included in the client's plan of care?

Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by inflammation and ulceration of the large intestine (colon) that results in abdominal pain, frequent bouts of bloody diarrhea, anorexia, and anemia. The nurse planning care for a client with UC should: Manage pain: Intestinal inflammation often produces severe abdominal pain that limits treatment compliance. Provide prescribed analgesics to promote comfort and treatment adherence (Option 1). Address psychosocial needs: Chronic illness may increase the risk of hopelessness and/or depression due to prolonged treatment and frustration over lack of improvement or symptom control. Encourage clients to discuss emotions and feelings (Option 2). Assess fluid balance: Diarrhea, blood loss, and poor oral intake contribute to dehydration. Strict intake and output monitoring helps ensure adequate fluid intake and prevent dehydration (Option 3). Evaluate treatment adherence: UC exacerbations may be spontaneous or may be precipitated by certain foods or lack of adherence to prescribed treatments (eg, medications). Assess compliance with prescribed treatments and provide education as needed to promote adherence (Option 4). Promote nutrition: Pain after eating may lead to anorexia, and intestinal inflammation decreases nutrient absorption; both result in nutritional deficiency. Help clients select nutrient-dense, high-protein foods to promote recovery and meet nutritional needs (Option 5).

The nurse is providing discharge teaching to a client newly diagnosed with ulcerative colitis. Which of the following statements by the client indicate that teaching has been effective?

Ulcerative colitis (UC) is a form of inflammatory bowel disease characterized by remitting periods of mucosal irritation in the large intestine, resulting in profuse, bloody diarrhea. Management of clients with UC often includes dietary interventions to reduce symptoms and prevent reoccurrence, malnutrition, and dehydration. Nutrition and hydration management: Diets consisting of high-calorie, high-protein foods are recommended to prevent weight loss and muscle wasting (Option 1). Multivitamins containing calcium are often prescribed to supplement nutrition and should be taken regardless of symptoms (Option 2). Oral hydration is critical in UC as >10 liquid stools may occur daily during flares, placing clients at risk for dehydration. Instruct clients to drink at least 2 liters of water daily (Option 4). Dietary triggers for UC vary greatly between individuals and may include dairy, nuts/legumes, cereal, alcohol, caffeine, and fatty and processed foods. Diet journaling is recommended to assist with identifying triggers (Option 5). Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided (Option 3).

The family practice clinic nurse is conducting client intake histories. Which client findings or histories indicate a need for heightened concern that the client may have cancer?

Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss (Option 4). The warning signs of cancer can be remembered with the acronym CAUTION: -Change in bowel or bladder habits -A sore that does not heal -Unusual bleeding or discharge from a body orifice -Thickening or a lump in the breast or elsewhere -Indigestion or difficulty in swallowing -Obvious change in a wart or mole -Nagging cough or hoarseness (Option 3) Although 99% of breast cancers are found in women, men can also develop breast cancer, especially if risk factors, such as past chest radiation, are present. Later signs of breast cancer include a newly retracted nipple or an orange-peel appearance of the breast tissue (peau d'orange) caused by the plugging of dermal lymph drainage (Option 5). (Option 1) BPH is caused by hormonal changes related to aging. Growth is not related to cancer. (Option 2) Lipomas are benign, fatty masses and rarely become malignant. They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic. Masses that are hard and fixed, not soft and mobile, usually indicate malignancy.

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L). The nurse should anticipate which findings?

A normal hemoglobin level for an adult male is 13.2-17.3 g/dL (132-173 g/L) and female is 11.7-15.5 g/dL (117-155 g/L). A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath (dyspnea) may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor (pale complexion) occurs from reduced blood flow to the skin. (Option 1) Coarse crackles occur with fluid overload but not with anemia. (Option 4) Respiratory depression does not occur with anemia. Respiratory depression may occur post-administration of a narcotic or during oversedation.

A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first?

Acute blood loss is a medical emergency, and the nurse needs to carry out interventions rapidly. Lowering the head of the bed or placing the client in the supine position maintains blood perfusion to the brain and other vital organs. This can be done quickly to help stabilize the client before performing other interventions. (Option 1) Assessing and recording vital signs is appropriate and should be reported to the health care provider, but this is not the priority. (Option 2) Monitoring hemoglobin and hematocrit levels is appropriate to assess the severity of blood loss and need for possible blood transfusion. Blood loss typically takes a few hours to reflect on the client's laboratory report; therefore, this is not the priority. (Option 4) Ensuring IV access and continuing fluid administration is appropriate. This maintains fluid volume due to blood loss and corrects or reduces potential for hypovolemic shock. This can be done after lowering the head of the bed.

Which group of food selections would be the best choice for a client advancing to a full liquid diet 3 days after bariatric surgery?

Bariatric surgery (eg, gastric banding, sleeve gastrectomy) reduces stomach capacity. A client's bariatric postoperative diet is restricted to foods that are low in simple carbohydrates and high in nutrients (eg, protein, fiber). After gastric surgery, consumption of simple carbohydrates can lead to dumping syndrome (ie, cramping, diarrhea). The client will tolerate only small meals of clear liquids at first, advance to full liquids 24-48 hours after surgery, and then progress gradually to solid foods as the gastrointestinal tract heals. Small, frequent meals are recommended to avoid overstretching of the pouch and to prevent nausea, vomiting, and regurgitation. The best food choices for a bariatric full liquid diet are cream soups, refined cooked cereals, sugar-free drinks, and low-sugar protein shakes and dairy foods (Option 3). (Option 1) Fruit juices and puddings are high in sugar and not acceptable for a bariatric full liquid diet. Mashed potatoes are considered appropriate for a soft diet. (Option 2) Ice cream is high in sugar and not acceptable for a bariatric full liquid diet. Eggs are appropriate for a soft diet. (Option 4) Yogurt is high in sugar and not appropriate for a bariatric full liquid diet. Peanut butter and vegetable juice are appropriate for a soft diet.

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. Which meal does the client choose to indicate that teaching has been effective?

Iron-deficiency anemia occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin. Iron-deficiency anemia can result from: Diets low in iron (eg, vegetarian and low-protein diets) Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome) Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding) Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids]) Foods rich in iron include: Meats (eg, beef, lamb, liver, chicken, pork) Shellfish (eg, oysters, clams, shrimp) Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with iron-rich foods will enhance iron absorption but coffee and tea consumption interferes with this process. (Option 1) Chicken in a salad is a good source of iron. However, bread, pudding, and milk do not contain significant amounts of iron. (Option 2) Fat-free yogurt, carrot sticks, apple slices, and diet soda do not offer a significant source of iron. (Option 3) Ham is a good source of iron. However, carrots, green beans, and gelatin desserts are not significant sources. Furthermore, the tea will inhibit iron absorption.

An 80-year-old client has been hospitalized with pneumonia and malnutrition. Physical assessment findings include weakness and decreased muscle mass. Which finding best indicates that the client is responding to treatment?

Malnutrition occurs due to inadequate intake of major nutrients (eg, calories, carbohydrates, fat, protein) or micronutrients (eg, minerals, vitamins). As malnutrition worsens and protein intake is reduced, muscles become fatigued and weak. Clinical manifestations depend on the severity of the malnutrition, ranging from mild to extreme (eg, emaciation). Weight gain is the best indicator that the client is responding to medical nutritional therapy. (Option 1) Consuming 90% of meals indicates that the client's appetite is good or improving but does not provide conclusive evidence of an improved nutritional status. (Option 2) Although a serum albumin level of 3.6 g/dL (36 g/L) is within the normal range of 3.5-5.0 g/dL (35-50 g/L), visceral protein stores are poor indicators of nutritional status in acute and chronic disease. During an inflammatory response (eg, pneumonia), protein synthesis by the liver is decreased. Serum albumin has a long half-life, so laboratory levels may not reflect the change in nutritional status for over 2 weeks. Prealbumin has a half-life of only 2 days and is quicker and more reliable than serum albumin as an indicator of acute change in nutritional status. (Option 4) A white blood cell count of 15,000/mm3 (15.0 × 109/L) is elevated (normal: 4,000-11,000/mm3 [4.0-10.0 × 119/L]), which indicates that the infection has not resolved.

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L). Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing?

Oncotic pressure (or colloid osmotic pressure) is a form of osmotic pressure exerted by plasma proteins (albumin) in the blood that pulls water into the circulatory system. Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a large plasma protein that remains in the vascular compartment. Albumin plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels. Clients with severe liver disease can develop hypoalbuminemiabecause the liver manufactures albumin, and damaged hepatocytes are unable to synthesize it. When serum albumin is low, oncotic pressure decreases and fluid leaks from the intravascular compartment into the interstitial spaces, causing pitting edema of the lower extremities, periorbital edema, and ascites (Option 4). (Options 1, 2, and 3) Altered mental status, easy bruising, and loss of body hair are manifestations of liver disease, not hypoalbuminemia. Altered mental status (hepatic encephalopathy) is due to elevated serum ammonia levels. Easy bruising is caused by an inability to produce prothrombin and other clotting factors. Loss of body hair is due to altered hormone metabolism.

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination?

Radiation damages the DNA, which causes cell destruction. Radiation (and chemotherapy) usually affects tissues with rapidly proliferating cells (eg, oral mucosa, gastrointestinal tract, bone marrow) first, followed by tissues with slowly proliferating cells (eg, cartilage, bone, kidney). As a result, early manifestations of radiation damage include oral mucosal ulcerations, vomiting/diarrhea, and low blood cell counts. The extent of radiation exposure can be monitored indirectly by measuring blood cell counts. (Option 1) A bitter almond smell on the client's breath is a classic sign of cyanide poisoning. (Option 2) Fever and raised skin pustules are signs/symptoms of smallpox, which is transmitted from person to person via respiratory droplets. Infection starts with fever, followed by a rash and then sharply raised pustules.

A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome?

Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphorous, potassium, and/or magnesium (mnemonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency. Actions to prevent refeeding syndrome include the following: Obtaining baseline electrolytes Initiating nutrition support cautiously with hypocaloric feedings Closely monitoring electrolytes Increasing caloric intake gradually (Option 2) These values are within normal ranges for phosphorus (2.4-4.4 mg/dL [0.78-1.42 mmol/L]), potassium (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), and magnesium (1.5-2.5 mEq/L [0.75-1.25 mmol/L]). In refeeding syndrome, the values for one or more of these electrolytes are decreased. (Option 3) These laboratory values are below normal ranges but are not associated with refeeding syndrome. (Option 4) These are normal laboratory values and are not associated with refeeding syndrome.

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD). The nurse anticipates which laboratory results for this client?

The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces more red blood cells (RBCs) to carry needed oxygen to the cells. A high RBC count is called polycythemia. (Option 1) Anemia is not expected and will worsen symptoms of COPD. (Option 2) Neutropenia (low white blood cell count) is not expected in COPD. Chemotherapy and many medications (clozapine [antipsychotic], methimazole [antithyroid]) can cause neutropenia which increases the risk of infection. (Option 4) Thrombocytopenia (low platelet count) is not anticipated in COPD. Alcohol use, HIV infection, and many medications (heparin) can cause thrombocytopenia.

After receiving report, which client should the nurse assess first?

Thrombocytopenia is a serious complication of heparin products (eg, unfractionated heparin and low-molecular-weight heparin [eg, enoxaparin]). Regardless of its cause, thrombocytopenia usually results in bleeding complications. However, in heparin-induced thrombocytopenia (HIT) this usually leads to paradoxical venous and/or arterial thrombosis and less commonly to bleeding. The mechanism for thrombosis is unclear. The danger of HIT is risk of organ damage from local thrombi and/or embolization, leading to stroke and/or pulmonary embolism. HIT occurs over several days. The nurse should monitor platelet levels of clients on heparin and report a decrease of ≥50% from baseline or a drop below 150,000/mm3 (150 x 109/L) to the health care provider. If the client has HIT, all heparin products must be stopped immediately, and a different anticoagulant (eg, argatroban) should be started to prevent thrombosis risk. (Option 2) This client with mildly elevated blood urea nitrogen (normal 6-20 mg/dL [2.1-7.1 mmol/L]) needs IV fluids. This is not the priority. (Option 3) The client with myelodysplastic syndrome does not produce adequate blood cells. Low white blood cell count, platelets, and hemoglobin are expected. Although this client is at risk for infection, HIT has a higher priority. (Option 4) Decreased hemoglobin and hematocrit are expected in sickle cell disease due to chronic/acute hemolysis. A packed red blood cell transfusion may be needed, but this is not the priority.

The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer?

Almost all cases of cervical cancer result from persistent infection due to human papillomavirus (HPV), a primary risk factor (Option 2). HPV is the most common sexually transmitted infection but is usually transient and resolves spontaneously. However, persistent HPV infection can cause abnormal changes in cervical epithelial tissue that slowly progress to invasive cancer if not treated. Most other risk factors for cervical cancer are related to behaviors that increase the client's risk of contracting HPV or an inability to clear the infection. Clients who have multiple sexual partners or initiate sexual activity at an early age (<18) increase their risk for exposure to HPV (Options 3 and 5). Clients with weakened immunity (eg, HIV, immunosuppressive therapy) may have an impaired ability to clear HPV, which increases the risk for cervical cancer due to persistent infection (Option 1). (Option 4) Nulliparity (ie, no previous pregnancies) is not a risk factor for cervical cancer; however, it is a risk factor for breast cancer.

The nurse is assessing a client who had an esophagogastroduodenoscopy 3 hours ago. The client is reporting increasing abdominal pain. Which clinical finding requires an immediate report to the health care provider?

An esophagogastroduodenoscopy (EGD) involves passing an endoscope down the esophagus to visualize the upper gastrointestinal structures (eg, esophagus, stomach, duodenum). Perforation of the gastrointestinal tract is a life-threatening complication of EGD that can lead to peritonitis and sepsis. Signs of perforation include a sudden temperature spike, increasing pain/tenderness, restlessness, tachycardia, and tachypnea. The nurse should notify the health care provider immediately if the client develops a fever (Option 4). (Option 1) Post-procedure changes in blood pressure can be caused by sedation, blood loss, or sepsis. Although the client had a slight decrease in blood pressure, it has remained relatively consistent with the other blood pressure readings and does not require immediate notification of the health care provider. (Option 2) An EGD involves applying a topical anesthetic to the throat to pass the endoscope. It may take a few hours for the gag reflex to return. Absent gag reflex after a prolonged period (eg, 6 hours) should be reported to the health care provider. (Option 3) A sore throat is expected after certain procedures (eg, EGD, intubation) due to local irritation. Warm saline gargles can provide some relief.

The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management?

Irritable bowel syndrome (IBS) is a common, chronic bowel condition caused by altered intestinal motility. Peristaltic action is affected, causing diarrhea, constipation, or a combination of both. Management focuses on reducing diarrhea or constipation, abdominal pain, and stress. Clients can manage symptoms with diet, medications, exercise, and stress management. To manage IBS, clients should restrict gas-producing foods (eg, bananas, cabbage, onions); caffeine; alcohol; fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) (eg, honey, high-fructose corn syrup, wheat); and other gastrointestinal (GI) irritants (eg, spices, hot/cold food or drink, dairy products, fatty foods). Clients should gradually increase fiber intake (eg, whole grains, legumes, nuts, fruits, vegetables) as tolerated. Foods that are generally well tolerated include proteins, breads, and bland foods (Option 4). (Option 1) Although they are a great source of fiber, beans are gas-producing and should be avoided. Most dairy products are GI irritants; however, yogurt is often better tolerated and may be included in the diet. (Option 2) Gas-producing cruciferous vegetables (eg, broccoli, cabbage) should be avoided. Alcohol exacerbates IBS symptoms. (Option 3) Hot beverages and caffeine (eg, coffee) irritate the GI tract. Bagels are gas-producing.