Module 8 - Chapter 41

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? A. Ineffective tissue perfusion related to bowel ischemia B. Imbalanced nutrition: Less than body requirements related to impaired absorption C. Anxiety related to bowel obstruction and subsequent hospitalization D. Impaired skin integrity related to bowel obstruction

A. Ineffective tissue perfusion related to bowel ischemia

A nurse is preparing to administer a client's intravenous fat emulsion simultaneously with parenteral nutrition (PN). What principle should guide the nurse's action? A. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. B. The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN. C. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. D. The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.

A. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrhea C. An absence of blood in stool D. Involvement of the rectal mucosa

C. An absence of blood in stool

A client is scheduled for the creation of a continent ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery? A. A minimum of 30 g of soluble fiber daily B. Increased intake of free water and clear juices C. High intake of strained fruits and vegetables D. A high-calorie, high-residue diet

C. High intake of strained fruits and vegetables

A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications? A. 5% deficit in body weight compared to pre-illness weight and increased caloric need B. Calorie deficit and muscle wasting combined with low electrolyte levels C. Inability to take in adequate oral food or fluids within 7 days D. Significant risk of aspiration coupled with decreased level of consciousness

C. Inability to take in adequate oral food or fluids within 7 days

A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem? A. Adherence to a high-fiber diet will help the polyps resolve. B. The client should be assured that this is a normal, age-related physiologic change. C. The client's polyps constitute a risk factor for cancer. D. The presence of polyps is associated with an increased risk of bowel obstruction.

C. The client's polyps constitute a risk factor for cancer.

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolyte balance

D. Maintaining fluid and electrolyte balance

A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse should prioritize what finding? A. White blood cell level B. Creatinine level C. Hemoglobin level D. Potassium level

D. Potassium level

A nurse is conducting health screening with a diverse group of clients. Which client likely has the most risk factors for developing hemorrhoids? A. A 45-year-old teacher who stands for 6 hours per day B. A pregnant woman at 28 weeks' gestation C. A 37-year-old construction worker who does heavy lifting D. A 60-year-old professional who is under stress

B. A pregnant woman at 28 weeks' gestation

A client with a diagnosis of colon cancer is 2 days' postoperative following bowel resection and anastomosis. The nurse has planned the client's care in the knowledge of potential complications. What assessment should the nurse prioritize? A. Close monitoring of temperature B. Frequent abdominal auscultation C. Assessment of hemoglobin, hematocrit, and red blood cell levels D. Palpation of peripheral pulses and leg girth

B. Frequent abdominal auscultation

A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? A. Use glycerin suppositories on a regular basis. B. Limit physical activity in order to promote bowel peristalsis. C. Consume high-residue, high-fiber foods. D. Resist the urge to defecate until the urge becomes intense.

C. Consume high-residue, high-fiber foods.

A nurse is caring for a client who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the client? A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. B. Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C. Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. D. Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.

A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.

The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? A. Antidiarrheal medications 30 minutes before a meal B. Antiemetics on a PRN basis C. Vitamin B12 injections to prevent pernicious anemia D. Beta adrenergic blockers to reduce bowel motility

A. Antidiarrheal medications 30 minutes before a meal

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? A. Checking the client's capillary blood glucose levels regularly B. Having the client frequently rate his or her hunger on a 10-point scale C. Measuring the client's heart rhythm at least every 6 hours D. Monitoring the client's level of consciousness each shift

A. Checking the client's capillary blood glucose levels regularly

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? A. Client will accurately identify foods that trigger symptoms. B. Client will demonstrate appropriate care of his ileostomy. C. Client will demonstrate appropriate use of standard infection control precautions. D. Client will adhere to recommended guidelines for mobility and activity.

A. Client will accurately identify foods that trigger symptoms.

A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? A. High levels of alcohol consumption B. History of bowel obstruction C. History of diverticulitis D. Longstanding psychosocial stress

A. High levels of alcohol consumption

A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tube B. Insertion of a central venous catheter C. Administration of a mineral oil enema D. Administration of a glycerin suppository and an oral laxative

A. Insertion of a nasogastric tube

A nurse is preparing to discharge a client home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. A. Preparing the client to troubleshoot for problems B. Teaching the client and family strict aseptic technique C. Teaching the client and family how to set up the infusion D. Teaching the client to flush the line with sterile water E. Teaching the client when it is safe to leave the access site open to air

A. Preparing the client to troubleshoot for problems B. Teaching the client and family strict aseptic technique C. Teaching the client and family how to set up the infusion

An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the client to take stool softener daily. B. Assess the client's food and fluid intake. C. Assess the client's surgical history. D. Encourage the client to take fiber supplements

B. Assess the client's food and fluid intake.

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? A. Use clean technique and wear a mask during dressing changes. B. Change the dressing no more than weekly. C. Apply antibiotic ointment around the site with each dressing change. D. Irrigate the insertion site with sterile water during each dressing change.

B. Change the dressing no more than weekly.

A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing action(s) relevant to what potential complications? Select all that apply. A. Dumping syndrome B. Clotted or displaced catheter C. Pneumothorax D. Hyperglycemia E. Line sepsis

B. Clotted or displaced catheter C. Pneumothorax D. Hyperglycemia E. Line sepsis

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? A. Administer a Fleet enema as prescribed and remain with the client. B. Contact the primary care provider promptly and report these signs of perforation. C. Position the client supine and insert an NG tube. D. Page the primary provider and report that the client may be obstructed.

B. Contact the primary care provider promptly and report these signs of perforation.

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action? A. Contact the care provider to have the client's hemoglobin and hematocrit measured. B. Document these expected assessment findings. C. Apply barrier ointment to the stoma as prescribed. D. Cleanse the stoma with alcohol or chlorhexidine.

B. Document these expected assessment findings.

A nurse is providing care for a client whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the client to conduct online research into colostomies. B. Engage the client in dialogue about the implications of having the colostomy. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D. Emphasize the fact that the colostomy is temporary measure and is not permanent.

B. Engage the client in dialogue about the implications of having the colostomy.

The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A. Recurrent constipation coupled with weight loss B. Foul-smelling diarrhea that contains fat C. Fever accompanied by a rigid, tender abdomen D. Bloody bowel movements accompanied by fecal incontinence

B. Foul-smelling diarrhea that contains fat

An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. A. Anticholinergic medications B. Increased fiber intake C. Enemas on alternating days D. Reduced fat intake E. Fluid reduction

B. Increased fiber intake D. Reduced fat intake

During a client's scheduled home visit, an older adult client has stated to the community health nurse that the client has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? A. Regular application of an OTC antibiotic ointment B. Increased fluid and fiber intake C. Daily use of OTC glycerin suppositories D. Use of an NSAID to reduce inflammation

B. Increased fluid and fiber intake

A nurse is caring for a client who is receiving parenteral nutrition. When writing this client's plan of care, which of the following nursing diagnoses should be included? A. Risk for peripheral neurovascular dysfunction related to catheter placement B. Ineffective role performance related to parenteral nutrition C. Bowel incontinence related to parenteral nutrition D. Chronic pain related to catheter placement

B. Ineffective role performance related to parenteral nutrition

A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse should initiate therapy by performing which of the following actions? A. Starting with a rapid infusion rate to meet the client's nutritional needs as quickly as possible B. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance C. Changing the rate of administration every 2 hours based on serum electrolyte values D. Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

B. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance

A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse. B. Report signs and symptoms of obstruction to the health care provider. C. Encourage the client to mobilize in order to enhance motility. D. Contact the health care provider and obtain a swab of the stoma for culture.

B. Report signs and symptoms of obstruction to the health care provider.

A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? A. Imbalanced nutrition: Less than body requirements related to decreased oral intake B. Risk for infection related to possible rupture of appendix C. Constipation related to decreased bowel motility and decreased fluid intake D. Chronic pain related to appendicitis

B. Risk for infection related to possible rupture of appendix

A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize? A. Risk for activity intolerance related to the presence of a subclavian catheter B. Risk for infection related to the presence of a subclavian catheter C. Risk for functional urinary incontinence related to the presence of a subclavian catheter D. Risk for sleep deprivation related to the presence of a subclavian catheter

B. Risk for infection related to the presence of a subclavian catheter

A nurse at an outpatient surgery center is caring for a client who had a hemorrhoidectomy. What discharge education topics should the nurse address with this client? A. The appropriate use of antibiotics to prevent postoperative infection B. The correct procedure for taking a sitz bath C. The need to eat a low-residue, low-fat diet for the next 2 weeks D. The correct technique for keeping the perianal region clean without the use of water

B. The correct procedure for taking a sitz bath

A client's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the client has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? A. Ensure that the client knows that he or she will be responsible for care after discharge. B. Reassure the client that many people are fearful after the creation of an ostomy. C. Acknowledge the client's reluctance and initiate discussion of the factors underlying it. D. Arrange for the client to be seen by a social worker or spiritual advisor.

C. Acknowledge the client's reluctance and initiate discussion of the factors underlying it.

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? A. Irrigate the ostomy to clear a possible obstruction. B. Contact the primary care provider to report this finding. C. Document that the stoma appears healthy and well perfused. D. Document a nursing diagnosis of Impaired Skin Integrity.

C. Document that the stoma appears healthy and well perfused.

A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge? A. The family's ability to take care of the client's special diet needs B. The family's ability to monitor the client's changing health status C. The family's ability to provide emotional support D. The family's ability to manage the client's medication regimen

C. The family's ability to provide emotional support

An older adult has a diagnosis of Alzheimer disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the client's stools. What is the nurse's most appropriate intervention? A. Keep a food diary to determine the foods that exacerbate the client's symptoms. B. Provide the client with a bland, low-residue diet. C. Toilet the client on a frequent, scheduled basis. D. Liaise with the primary provider to obtain an order for loperamide.

C. Toilet the client on a frequent, scheduled basis.

A client has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the client has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion? A. Annual screening colonoscopies B. Adherence to recommended immunization schedules C. Regular blood pressure monitoring D. Frequent screening for osteoporosis

D. Frequent screening for osteoporosis

Which of the following is the most plausible nursing diagnosis for a client whose treatment for colon cancer has necessitated a colostomy? A. Risk for unstable blood glucose due to changes in digestion and absorption B. Unilateral neglect related to decreased physical mobility C. Risk for excess fluid volume related to dietary changes and changes in absorption D. Ineffective sexuality patterns related to changes in self-concept

D. Ineffective sexuality patterns related to changes in self-concept

A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate? A. Reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy. B. Provide the client with educational materials that match the client's learning style. C. Encourage the client to write down these concerns and questions to bring forward to the surgeon. D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving the client's diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize? A. The effect of laxatives on electrolyte levels B. The underlying causes of constipation C. The risk of fecal incontinence D. The risk of becoming laxative-dependent

D. The risk of becoming laxative-dependent