Saunders Gastrointestinal

The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. Which statement should the nurse make to the client for consideration? 1. "Lie down for at least an hour after eating." 2. "Be sure to sleep with your head elevated in bed." 3. "This problem requires surgery most of the time." 4. "Eat foods that are higher in fat to slow down digestion."

"Be sure to sleep with your head elevated in bed." Most clients with hiatal hernia can be managed by conservative measures that include a low-fat diet, avoiding lying down for an hour after eating, and keeping the head of the bed elevated.

A sexually active 20-year-old client has been diagnosed with viral hepatitis. Which statement made by the client would indicate a need for further teaching? 1. "I can never drink alcohol again." 2. "I won't go back to work right away." 3. "My close friends should get the vaccine." 4. "A condom should be used for sexual intercourse."

1. "I can never drink alcohol again." To prevent transmission of hepatitis, a condom is advised during sexual intercourse, as well as vaccination of the partner or close friends. Alcohol should be avoided for 1 year because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that the liver function has returned to normal. The client's activity is increased gradually.

A client is seen in the ambulatory care office for a routine examination. Which statement by the client should be most important for the nurse to follow up? 1. "I just lost a family member to gastrointestinal cancer." 2. "It's been over 18 months since I last had my prostate checked." 3. "I have had a hard time following a low-sodium diet like I know I should." 4. "I avoid overly hot or spicy foods because they always give me heartburn."

1. "I just lost a family member to gastrointestinal cancer." The nurse should recognize and follow up on the statement about familial cancer. The client may have some anxiety that this will ultimately occur to him, and the nurse should gather further data to understand the client's situation. Gathering data about the types of cancer, age, and sex of affected family members and the presence of other risk factors provides the needed information to initiate preventive education. Options 2, 3, and 4 require follow-up but do not have the priority that the correct option has.

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to be prescribed? Select all that apply. 1. Administer antacids, as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics, as prescribed. 4. Maintain the client in a supine and flat position. 5. Encourage small, frequent, high-calorie feedings.

1. Administer antacids, as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics, as prescribed. The client with acute pancreatitis is normally placed on an NPO status to rest the pancreas and suppress GI secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may also help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions.

A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures will most likely promote coping? Select all that apply. 1. Ask a member of the local ostomy club to visit with the client before discharge. 2. Ask the enterostomal nurse specialist to consult with the client before discharge. 3. Remind the client frequently that infection is a major complication of a colostomy. 4. Remind the client frequently that he will be responsible for caring for the colostomy at home. 5. Ask the client to begin doing one part of the ostomy care each day and increase tasks daily.

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

The nurse notes that the medical record of a client diagnosed with cirrhosis states that the client has asterixis. To effectively verify this information the nurse should take which action? 1. Ask the client to extend the arms. 2. Instruct the client to lean forward. 3. Ask the client to dorsiflex the calf. 4. Measure the client's abdominal girth

1. Ask the client to extend the arms. Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. It is the most common and reliable sign that hepatic encephalopathy is developing.

A client with viral hepatitis states to the nurse, "I am so yellow." The nurse should best respond by taking which action? 1. Assist the client in expressing feelings. 2. Restrict visitors until the jaundice subsides. 3. Keep the client isolated from other clients and visitors. 4. Instruct the client that skin turning yellow is the consequence of alcoholism.

1. Assist the client in expressing feelings. The client's feelings should be explored to discover how the client feels about the disease process and appearance so appropriate interventions can be planned. Options 2, 3, and 4 are inappropriate.

The nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse explains to the client that it is important to continue to do which action after discharge? 1. Avoid coughing. 2. Irrigate the drain. 3. Maintain bed rest. 4. Restrict pain medication.

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

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record? 1. Diarrhea 2. Constipation 3. Bloody stools 4. Stool constantly oozing from the rectum

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

The nurse who is reinforcing instructions to a client who has had a gastric resection should include which considerations? Select all that apply. 1. Eat small frequent meals. 2. Avoid iron supplementation. 3. Take action to prevent dumping syndrome. 4. Self-monitor for signs of lower gastrointestinal (GI) bleeding. 5. Consume a diet that is relatively high in vitamin B12 content.

1. Eat small frequent meals. 3. Take action to prevent dumping syndrome. After a gastrectomy, small frequent meals are given until the stomach stretches enough to tolerate three regular meals a day. Dumping syndrome occurs in many clients after GI surgery and may occur as an early or late complication. Upper GI hemorrhage also may occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks the intrinsic factor needed for absorption. Instead the client requires injection to supplement this vitamin. Iron supplements are necessary to help absorption of parenteral vitamin B12.

A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which considerations concerning ongoing self-management should the nurse reinforce to the client? Select all that apply. 1. Eat smaller and more frequent meals. 2. Resume full activity almost immediately. 3. Drink fluids between meals not with them. 4. Stress will do little to exacerbate gastrointestinal symptoms. 5. Follow-up visits with the primary health care provider will no longer be needed.

1. Eat smaller and more frequent meals. 3. Drink fluids between meals not with them. Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. Fluids should be taken between meals not with them to avoid dumping syndrome. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client requires ongoing medical supervision and evaluation.

The nurse should document that a client diagnosed with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action? 1. Eating low-fat or nonfat foods 2. Elevating the foot of the bed during sleep 3. Doing household chores immediately after eating 4. Sleeping with the head of the bed slightly down

1. Eating low-fat or nonfat foods The use of low-fat or nonfat foods is recommended to reduce gastric pressure and prevent sliding of the hernia through the cardiac sphincter. The client should also elevate the head of the bed during sleep and wait at least 1 hour after meals to perform chores.

A client is admitted to the hospital with a diagnosis of acute viral hepatitis. Which sign/symptom should the nurse expect to observe based on this diagnosis? 1. Fatigue 2. Pale urine 3. Weight gain 4. Spider angiomas

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

The nurse is interpreting the laboratory results of a client who has a history of diagnosed chronic ulcerative colitis. The nurse should determine that which result indicates a complication of ulcerative colitis? 1. Hemoglobin 10.2 g/dL 2. Potassium 4.1 mEq/L 3. Prothrombin time 10.9 seconds 4. White blood cell count 6300 mm3

1. Hemoglobin 10.2 g/dL A normal hemoglobin level ranges from 12 to 16 g/dL. The client with ulcerative colitis is most likely anemic because of chronic blood loss in small amounts with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. The other laboratory results are within a normal range.

It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

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

Which infection control method should the nurse determine to be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure? 1. Hepatitis B vaccine 2. Proper personal hygiene 3. Use of immune globulin 4. Correct hand-washing technique

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

The client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which additional data from the client to support this diagnosis? 1. History of alcohol use, smoking, and weight loss 2. Frequent "heartburn" with a sour taste in the mouth 3. Complaints of stress with a history of chronic kidney disease 4. Blood group and history of chronic obstructive pulmonary disease with weight gain

1. History of alcohol use, smoking, and weight loss Alcohol use, smoking, and weight loss are most commonly associated with gastric ulcers. The other options do not identify risk factors commonly associated with this disorder. The symptoms listed in option 2 may be seen in gastroesophageal reflux disease.

A client with a diagnosis of acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic prescription on the primary health care provider prescription sheet, the nurse should suggest contacting the primary health care provider to request a prescription for which medication? 1. Hydromorphone 2. Morphine sulfate 3. Acetylsalicylic acid 4. Acetaminophen with codeine

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

The nurse caring for a client diagnosed with acute pancreatitis and has a history of alcoholism is monitoring the client for complications. The nurse determines that which data collected is most likely indicative of paralytic ileus? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margin

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

An acutely ill looking client arrives at the emergency department. The client complains of "the worst pain I ever felt in my belly. I can't get comfortable." The client is quiet but with each movement the client cries out in pain. The nurse suspects the client has peritonitis. Which data should the nurse collect to assist in validating this suspicion? Select all that apply. 1. Inspect the abdomen for rigidity. 2. Check for the presence of hiccups. 3. Check for the presence of bradycardia. 4. Auscultate the abdomen for borborygmi. 5. Inspect the client's mucous membranes.

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

The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which considerations should the nurse include in the teaching session? Select all that apply. 1. It is advisable to stop smoking cigarettes. 2. Lie flat for at least 30 minutes after meals. 3. Wait at least 1 hour after meals to perform chores. 4. Be sure to elevate the head of the bed during sleep. 5. Foods with moderate fat should be a part of your diet

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

The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. Which settings should the nurse anticipate to be prescribed by the primary health care provider? Select all that apply. 1. Low 2. High 3. Medium 4. Continuous 5. Intermittent

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

A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? 1. Lying recumbent after meals 2. Eating small, frequent, bland meals 3. Raising the head of the bed on 6-inch blocks 4. Taking histamine receptor antagonist medication, as prescribed

1. Lying recumbent after meals Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm, where the esophagus usually is positioned. The client generally experiences pain caused by reflux resulting from ingestion of irritating foods, lying flat following meals or at night, and consuming large or fatty meals. Relief is obtained by eating small, frequent, and bland meals; histamine antagonists and antacids; and elevation of the thorax after meals and during sleep.

The nurse is caring for a client in the emergency department who has right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescription? 1. Milk of magnesia 2. Nothing per mouth (NPO) 3. Cold pack to the abdomen 4. Intravenous (IV) fluids at a rate of 100 mL/hr

1. Milk of magnesia A client with right lower quadrant pain may have appendicitis. This client should be NPO and given IV fluids for hydration. Cold packs may provide comfort. Laxatives are not prescribed; therefore, the nurse should question this prescription.

The client in an emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply. 1. Milk of magnesia 2. Heat pad to the abdomen 3. Cold pack to the abdomen 4. Nothing per mouth (NPO) 5. Intravenous fluids at a rate of 100 mL/hr

1. Milk of magnesia 2. Heat pad to the abdomen A client with right lower quadrant abdominal pain may have appendicitis. This client would be NPO and given intravenous (IV) fluids for hydration. Cold packs may provide comfort. Laxatives are not prescribed; heat might bring enough blood and fluid to the appendix to cause it to rupture and cause peritonitis; therefore, the nurse would question the cathartic prescription and heat application.

A client with a diagnosis of viral hepatitis has no appetite, and food makes the client nauseated. The nurse should conclude that which intervention is most appropriate? 1. Offer small, frequent meals. 2. Encourage foods low in calories. 3. Explain that high-fat diets are usually better tolerated. 4. Explain that the majority of calories needs to be consumed in the evening hours.

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

A morbidly obese client, 3 days postoperative gastric bypass surgery, comes to the clinic complaining of pain. The nurse suspects that the client has an anastomotic leak requiring hospitalization. The nurse should determine that which findings best validate this suspicion? Select all that apply. 1. Oliguria 2. Restlessness 3. Abdominal pain 4. Nausea and vomiting 5. Unexplained tachycardia

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

The nurse is collecting data on a client admitted to the hospital with a diagnosis of hepatitis. The nurse should determine which data indicates the client may have liver damage? 1. Pruritus 2. Cool dry skin 3. Dark brown stools 4. Yellow, straw-colored urine

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

A client has undergone subtotal gastrectomy, and the nurse is preparing the client for discharge. Which item should be included when reinforcing instructions to the client about ongoing self-management? 1. Smaller, more frequent meals should be eaten. 2. The client can resume full activity immediately. 3. Stress can no longer exacerbate gastrointestinal symptoms. 4. Follow-up visits with the primary health care provider are no longer needed.

1. Smaller, more frequent meals should be eaten. Following gastric surgery the client should eat smaller, more frequent meals to facilitate digestion. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client does require ongoing medical supervision and evaluation.

A client has undergone subtotal gastrectomy, and the nurse is preparing the client for discharge. Which item should be included when reinforcing instructions to the client about ongoing self-management? 1. Smaller, more frequent meals should be eaten. 2. The client can resume full activity immediately. 3.Stress can no longer exacerbate gastrointestinal symptoms. 4. Follow-up visits with the primary health care provider are no longer needed.

1. Smaller, more frequent meals should be eaten. Following gastric surgery the client should eat smaller, more frequent meals to facilitate digestion. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client does require ongoing medical supervision and evaluation.

The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. The nurse should determine that which data noted in the record indicate poor absorption of dietary fats? 1. Steatorrhea 2. Bloody diarrhea 3. Electrolyte disturbances 4. Gastrointestinal reflux disease

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

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. The nurse should take which appropriate action? 1. Stop the irrigation temporarily. 2. Increase the height of the irrigation. 3. Medicate for pain and resume irrigation. 4. Notify the registered nurse immediately.

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

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? 1. Sweating and pallor 2. Dry skin and stomach pain 3. Bradycardia and indigestion 4. Double vision and chest pain

1. Sweating and pallor Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse should take which immediate action? 1. Take the client's vital signs. 2. Perform a complete abdominal assessment. 3. Obtain a thorough history of the recent health status. 4. Prepare to insert a nasogastric (NG) tube and test pH and occult blood.

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

A primary health care provider is about to perform a paracentesis on a client diagnosed with abdominal ascites. The nurse should assist the client to assume which position? 1. Upright 2. Supine 3. Left side-lying 4. Right side-lying

1. Upright An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. Ideally, the client sits upright in a chair, with feet flat on the floor, and with the bladder emptied before the procedure. Therefore, options 2, 3, and 4 are incorrect.

The nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement is most appropriate to be included in the teaching? 1. "Be sure to sleep with your bed flat." 2. "Avoid lying down for an hour after eating." 3. "This problem is best resolved with a surgical procedure." 4. "Eat foods that are higher in fat in order to slow down digestion."

2. "Avoid lying down for an hour after eating." Most clients with a hiatal hernia can be managed by conservative measures, which include a low-fat diet, avoiding lying down for an hour after eating, and raising the head of the bed.

The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. Which statement should the nurse make to the client for consideration? 1. "Lie down for at least an hour after eating." 2. "Be sure to sleep with your head elevated in bed." 3. "This problem requires surgery most of the time." 4. "Eat foods that are higher in fat to slow down digestion."

2. "Be sure to sleep with your head elevated in bed." Most clients with hiatal hernia can be managed by conservative measures that include a low-fat diet, avoiding lying down for an hour after eating, and keeping the head of the bed elevated.Most clients with hiatal hernia can be managed by conservative measures that include a low-fat diet, avoiding lying down for an hour after eating, and keeping the head of the bed elevated.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. The nurse should plan care, knowing that most likely, which problem will occur with this disorder? 1. Excess fluid volume related to sodium retention 2. Alteration in comfort related to abdominal pain 3. Alteration in fluid and electrolyte balance related to hyperkalemia 4. Potential for hypoglycemia related to a low blood glucose secondary to increased insulin secretion

2. Alteration in comfort related to abdominal pain Abdominal pain is the predominant symptom of acute pancreatitis. Shock and hypovolemia may occur from hemorrhage, toxemia, or loss of fluid into the peritoneal space. Potassium and sodium may be lost due to gastric suction and frequent vomiting. Hyperglycemia may result from impaired carbohydrate metabolism.

A client has undergone esophagogastroduodenoscopy (EGD). The nurse should place highest priority on which action as part of the client's care plan? 1. Monitoring the temperature 2. Checking for return of a gag reflex 3 Giving warm gargles for a sore throat 4. Monitoring for complaints of heartburn

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

A client has undergone esophagogastroduodenoscopy (EGD). The nurse should place highest priority on which action as part of the client's care plan? 1. Monitoring the temperature 2. Checking for return of a gag reflex 3. Giving warm gargles for a sore throat 4 Monitoring for complaints of heartburn

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

A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse assisting with caring for the client should take which action to monitor the effectiveness of treatment? 1. Monitoring the leukocyte count for 2 days after the infusion 2. Checking the frequency and consistency of bowel movements 3. Checking serum liver enzyme levels before and after the infusion 4. Carrying out a Hematest on gastric fluids after the infusion is completed

2. Checking the frequency and consistency of bowel movements The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication.

The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to digest food. The nurse determines that which processes are involved in the complete digestive process? Select all that apply. 1. Osmosis 2. Chemical 3. Filtration 4. Absorption 5. Mechanical 6. Active transport

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

A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom? 1. Dizziness after meals 2. Difficulty swallowing 3. Left lower quadrant pain 2 hours after eating 4. Moderate right upper quadrant pain unrelated to eating

2. Difficulty swallowing Although many clients with hiatal hernia are asymptomatic those with symptoms usually have difficulty swallowing, along with heartburn and reflux. Options 1, 3, and 4 are unrelated to this disorder.

A client is resuming a diet after partial gastrectomy. To minimize complications, the nurse should instruct the client to avoid which behavior? 1. Lying down after eating 2. Drinking liquids with meals 3. Eating six small meals per day 4. Excluding concentrated sweets in the diet

2. Drinking liquids with meals The client who has had a hemigastrectomy is at risk for dumping syndrome. This client should be placed on a diet that is high in protein, moderate in fat, and high in calories. The client should avoid drinking liquids with meals. Frequent small meals are encouraged, and the client should avoid concentrated sweets.

The nurse is collecting admission data on the client with a diagnosis of hepatitis. Which finding should the nurse recognize to be a direct result of this client's condition? 1. Diarrhea 2. Drowsiness 3. Blurred vision 4. Urinary frequency

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

The nurse is instructing a client who had a herniorrhaphy about how to reduce postoperative swelling following the procedure. Which should the nurse suggest to the client to prevent swelling? 1. Limit fluids. 2. Elevate the scrotum. 3. Apply heat to the abdomen. 4. Maintain a low-roughage diet.

2. Elevate the scrotum. Following herniorrhaphy, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The client also is instructed to apply a scrotal support when out of bed. Options 1, 3, and 4 are incorrect.

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. Which interventions should be included in the procedure? Select all that apply. 1. Remove the air from the balloon. 2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continuous steady motion. 5. Remove the device or tape securing the tube from the nose.

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

A client diagnosed with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is most likely a result of which condition that is part of the client's health history? 1. Hypothyroidism 2. Hemigastrectomy 3. Excessive vitamin C intake 4. Decreased dietary intake of iron

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

The nurse analyzes the results of laboratory studies performed on a client with diagnosed peptic ulcer disease (PUD). Which laboratory value would most indicate a complication associated with the disease? 1. Creatinine 1 mg/dL 2. Hemoglobin 10.2 g/dL 3. Platelet count of 400,000 mm3 4. White blood cell count of 5000 mm3

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

The nurse is reviewing the medication record of a client with a diagnosis of acute gastritis. Which medication noted on the client's record should the nurse most likely question? 1. Digoxin 2. Ibuprofen 3. Furosemide 4. Propranolol hydrochloride

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

A client has had a partial gastrectomy and the nurse is reinforcing discharge instructions. The nurse should reinforce instructions to the client about the need for which supplements? Select all that apply. 1. Antacid use 2. Iron supplements 3. Antibiotic therapy 4. Calcium supplements 5. Vitamin B12 injections

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

A client has been diagnosed with acute gastroenteritis. Which diet should the nurse anticipate to be prescribed for the client? 1. Low fat 2. Low fiber 3. High fiber 4. High carbohydrate

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

The client diagnosed with acute pancreatitis is experiencing severe pain from the disorder. The nurse should instruct the client to avoid which position that could aggravate the pain? 1. Sitting up 2. Lying flat 3. Leaning forward 4. Flexing the left leg

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

The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, the nurse should focus on which priority intervention? 1. Providing the client with an oral diet 2. Maintaining a patent nasogastric (NG) tube 3. Promoting the use of stress reduction techniques 4. Teaching the client about the symptoms of dumping syndrome

2. Maintaining a patent nasogastric (NG) tube An NG tube is inserted during surgery and is left in place for 24 to 48 hours to decompress the gastrointestinal tract which enhances sealing of the suture line. It is essential that the NG tube does not become occluded because this could disrupt the suture lines if distention occurs. The other options are also appropriate, but not within the first 24 hours following surgery.

Implemented treatment measures for a client with a diagnosis of bleeding esophageal varices have been unsuccessful. The primary health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse should prepare for insertion of this tube via which route? 1. Oral-gastric 2. Nasogastric 3. Gastrostomy 4. Percutaneous

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

A client is admitted to the hospital with a diagnosed bowel obstruction secondary to a recurrent diagnosed malignancy. The primary health care provider plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, which action should the nurse determine is best? 1. Leave the room. 2. Remain with the client and be silent. 3. Ask the client whether he would like another nurse to care for him. 4. Explain to the client that all clients have the right to know about medical procedures.

2. Remain with the client and be silent. The nurse needs to recognize that the client has a greater need for security and acceptance than education. In option 2, the nurse conveys acceptance of the client and uses the therapeutic communication technique of silence. Options 1, 3, and 4 block communication and do not address the client's need.

A primary health care provider asks the licensed practical nurse (LPN) to reinforce preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN should include which instruction in this discussion? 1. Eat a regular supper and breakfast. 2. Remove all metal and jewelry before the test. 3. Continue to take all oral medications as scheduled. 4. Expect diarrhea for a few days after the procedure.

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

The nurse is assisting with admitting a client to the hospital for the treatment of diagnosed dehydration. The client reports nausea, vomiting, diarrhea, and cramping for the past week. The nurse asks the client about medications being taking. The client denies taking prescription medications but states he has been taking some herbs given to him by a cousin. The nurse should alert the registered nurse when the client states he has been taking which herb? 1. Dill 2. Senna 3. Kaolin 4. Green tea

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

A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which data finding best indicates adequate location of the tube? 1. Bowel sounds are absent. 2. The aspirate from the tube has a pH of 7.45. 3. The aspirate from the tube has a pH of 6.5. 4. The tube can be palpated to the right of the umbilicus

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

A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which data finding best indicates adequate location of the tube? 1. Bowel sounds are absent. 2. The aspirate from the tube has a pH of 7.45. 3. The aspirate from the tube has a pH of 6.5. 4. The tube can be palpated to the right of the umbilicus.

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

The nurse is providing care for a client with a nasogastric tube. Which observation is most appropriate in determining that the tube is correctly placed? 1. The aspirate is dark green. 2. The pH of the aspirate is 5. 3. The aspirate is negative for guaiac. 4. The tube length was correctly measured before insertion.

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

A generally healthy 63-year-old man is seen in the primary health care provider's office for a routine examination. Which statement made by the client is most important for the nurse to follow up on? 1. "I check my stool yearly for occult blood." 2. "I have been following the balanced diet plan that the doctor gave me." 3. "Everyone in my immediate family has died from gastrointestinal cancer." 4. "I try to avoid overly hot or spicy foods because they give me heartburn sometimes."

3. "Everyone in my immediate family has died from gastrointestinal cancer." The nurse should follow up on the statement about familial cancer. The client may have some anxiety that this will ultimately occur to him and the nurse should gather further data to understand the client's situation and to identify additional risk factors. Options 1, 2, and 4 identify appropriate client behaviors regarding the prevention and detection of gastrointestinal cancer.

The nurse has given the client diagnosed with hepatitis instructions about post discharge management during convalescence. The nurse determines a need for further teaching if the client makes which statement? 1. "I should avoid alcohol and aspirin." 2. "I should eat a high-carbohydrate, low-fat diet." 3. "I should resume a full activity level within 1 week." 4. "I should take the prescribed amounts of vitamin K."

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

Which statement by the spouse of a client with diagnosed end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding management of the client's pain? 1. "If constipation is a problem, increased fluids will help." 2. "If the pain increases, I must let the doctor know immediately." 3. "This opioid will cause very deep sleep, which is what my husband needs." 4. "I should have my husband try the breathing exercises to help control pain."

3. "This opioid will cause very deep sleep, which is what my husband needs." Changes in level of consciousness are an indicator of potential opioid overdose and are indicative of numerous fluid, electrolyte, and oxygenation deficits. It is important for the spouse to understand the differences in sleep related to the relief of pain and changes in neurological status related to overdose or deficits. All remaining options are indicative of an understanding of appropriate steps to be taken in the management of pain.

A client is admitted to an acute care facility with complications of celiac disease. Which question asked by the nurse initially should be most helpful in obtaining information for the nursing care plan? 1. "How long have you been diagnosed?" 2. "What types of foods do you like to eat?" 3. "What is your understanding of celiac disease?" 4. "Have you eliminated whole wheat bread from your diet?"

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

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse should most appropriately suggest which diet during the acute phase? 1. A low-fat diet 2. A high-fat diet 3. A low-fiber diet 4. A high-carbohydrate diet

3. A low-fiber diet A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is usually prescribed during the acute phase for acute diverticulitis, ulcerative colitis, and irritable bowel syndrome. Once the acute phase has subsided the health care provider usually prescribes a high fiber diet. The diets identified in options 1, 2, and 4 will not aid in symptom management in acute diverticulitis.

The client arrives at an emergency department complaining of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the primary health care provider's prescriptions. Which prescription should the nurse most likely question if written on the primary health care provider's prescription form? 1. Insertion of a nasogastric (NG) tube 2. Insertion of an intravenous (IV) line 3. Administration of an opioid analgesic 4. Maintaining a nothing-by-mouth (NPO) status

3. Administration of an opioid analgesic Until a differential diagnosis is determined and a decision about the need for surgery is made, the nurse should question a prescription to give an opioid analgesic because it could mask the client's symptoms. The nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of an NG tube may be helpful to provide decompression of the stomach.

The nurse gathers data from a client admitted to the hospital with a diagnosis of gastroesophageal reflux disease (GERD) scheduled for a Nissen fundoplication. Based on an understanding of this disease, the nurse should determine that the client may be most at risk for which complication? 1. Diarrhea 2. Belching 3. Aspiration 4. Abdominal pain

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

The nurse has a prescription to give 30 mL of an antacid through a nasogastric (NG) tube connected to wall suction. The nurse should do which best action to perform this procedure correctly? 1. Position the client supine to assist in medication absorption. 2. Aspirate the NG tube following medication administration to maintain patency. 3. Clamp the NG tube for 30 minutes following administration of the medication. 4. Adjust the suction to a low-intermittent setting for an hour after medication administration.

3. Clamp the NG tube for 30 minutes following administration of the medication. If a client has an NG tube connected to suction the nurse clamps the tube and waits 20 to 30 minutes before reconnecting the tube to the suction. This allows adequate time for medication absorption. Options 2 and 4 both result in removal of the medication that has just been administered. The client should not be placed in the supine position because of risk of aspiration.

A primary health care provider places a Miller-Abbott tube in a client who has a diagnosed bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next? 1. Initiate a tube feeding. 2. Notify the registered nurse. 3. Document the finding in the client's record. 4. Pull the tube out 6 cm, and secure the tube to the nose with tape.

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

A client admitted to the hospital diagnosed with severe jaundice is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall to maintain muscle strength. The client paces around the room but will not enter the hall. The nurse should determine which concern is most likely the reason for the client's reluctance to walk in the hall? 1. Unfamiliarity with the hospital 2. Fear of catching another disease 3. Feeling self-conscious about appearance 4. Not wanting to overexert and get overtired

3. Feeling self-conscious about appearance Clients with jaundice frequently have a body image disturbance because of a change in appearance. This can be manifested in negative verbal or nonverbal behavior. Options 1, 2, and 4 are unrelated to the data in the question.

The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse should place the client in which position during and after the feedings? 1. Sims' 2. Supine 3. Fowler's 4. Trendelenburg's

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

A licensed practical nurse (LPN) is assisting in the insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by performing which measurement? 1. A 30-inch length on the tube 2. An 18-inch length on the tube 3. From the tip of the client's nose to the earlobe and then down to the xiphoid process 4. From the tip of the client's nose to the earlobe and then down to the top of the sternum

3. From the tip of the client's nose to the earlobe and then down to the xiphoid process The correct method for measuring the length of tube is to place the tube at the tip of the client's nose and measure by extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches.

A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom associated with a hiatal hernia should the nurse recognize? 1. Dry cough 2. Left lower quadrant pain 3. Heartburn and regurgitation 4. Moderate right upper quadrant pain

3. Heartburn and regurgitation Although many clients with a hiatal hernia are asymptomatic, those with symptoms usually have difficulty swallowing along with heartburn and reflux. Options 1, 2, and 4 are not related to this disorder.

The nurse is working with a client diagnosed with anorexia nervosa. As the nurse plans care, which should be focused on as the primary problem? 1. Pain 2. Depression 3. Impaired nutritional status 4. Lack of nutritional knowledge

3. Impaired nutritional status A client with anorexia nervosa has a decreased appetite, which can be a result of any number of causes. The plan of care primarily focuses on the risk of impaired nutritional status. The other options listed may or may not be associated with this client's diagnosis.

The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include during client teaching to help prevent dumping syndrome? 1. Ambulate after a meal. 2. Eat high-carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high-Fowler's position during meals.

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

The nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse should anticipate a prescription to set the suction to which pressure? 1. Low and continuous 2. High and intermittent 3. Low and intermittent 4. High and continuous

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

The nurse will be providing postprocedure care to a client who has undergone esophagogastroduodenoscopy (EGD). Based on the procedure done, the nurse should plan to do which action first? 1. Measure the client's temperature. 2. Give warm gargles for sore throat. 3. Monitor for return of the gag reflex. 4. Monitor for complaints of heartburn.

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

A client that is postgastrectomy is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse should plan to monitor which data? 1. Client's daily weights 2. Fasting blood glucose readings 3. Postprandial blood glucose readings 4. Calorie counts from the dietary department

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

The nurse is caring for a client with a Sengstaken-Blakemore tube. To effectively prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to implement which action? 1. Provide tracheal suction as needed. 2. Keep scissors at the bedside for emergency deflation. 3. Provide frequent oral and nasal care on a regular basis. 4. Have a family member remain with the client as much as possible.

3. Provide frequent oral and nasal care on a regular basis. Frequent oral and nasal care is necessary to prevent irritation to the mucosa. A family member's presence will not prevent this from occurring nor will the actions taken in options 1 and 2. Keeping scissors at the bedside is a good action; however, these are used to cut the tube if the client begins to have airway maintenance problems.

A client diagnosis of a peptic ulcer scheduled for a vagotomy asks the nurse about the purpose of this procedure. The nurse should explain to the client that a vagotomy primarily serves which purpose? 1. Halts stress reactions 2. Heals the gastric mucosa 3. Reduces the stimulation of acid secretions 4. Decreases food absorption in the stomach

3. Reduces the stimulation of acid secretions A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options 1, 2, and 4 are incorrect descriptions of a vagotomy.

A client that is postgastrectomy being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I may lose my job." Based on the client's statement, the nurse should determine that at this time, it is most appropriate to discuss which topic? 1. Wound care 2. An exercise program 3. Reducing stressors in life 4. The postgastrectomy diet

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

The nurse is reviewing the primary health care provider's (PHCP'S) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription should the nurse verify if noted in the client's chart? 1. NPO status 2. An anticholinergic medication 3. Supine and flat client positioning 4. Insertion of a nasogastric tube

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

A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN should assist the client into which most appropriate position? 1. Sims' 2. Supine with the head and feet flat 3. Supine with the head raised slightly and the knees slightly flexed 4. Semi-Fowler's with the head raised 45 degrees and the knees flat

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

The nurse is caring for a client with a neurogenic bowel due to a lower motor neuron spinal cord injury below T12 resulting in flaccid functionality. Besides triggering or facilitating techniques for defecation, what are some of the strategies the nurse needs to address to reestablish defecation patterns? Select all that apply. 1. Limit fluids 2. Low-fiber diet 3. Suppository use 4. Manual disimpaction 5. Consistent toileting schedule 6. Drinks with caffeine (coffee, tea, cocoa) and many soft drinks

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

The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction to the client? 1. Avoid iron supplementation. 2. Eat a diet high in vitamin B12. 3. Take actions to prevent dumping syndrome. 4. Self-monitor for signs and symptoms of lower gastrointestinal hemorrhage.

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

The nurse is reinforcing instructions to a client about insertion of a Sengstaken-Blakemore tube. Which statement by the client indicates a need for further teaching? 1. The tube will be inserted by my primary health care provider. 2. The tube will be inserted through my nose to my stomach. 3. The tube will be inserted through my mouth to my stomach. 4. The tube will be inserted to control bleeding of my esophagus

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

A calcium supplement is prescribed for a client diagnosed with hypoparathyroidism in the management of hypocalcemia. The client arrives at the clinic for a follow-up visit and complains of chronic constipation, and the nurse reinforces instructions to the client about measures to alleviate the constipation. Which comment by the client would indicate a need for further teaching? 1. "I need to increase my daily fluid intake." 2. "I need to increase my intake of high-fiber foods." 3. "I need to increase my activity level as tolerated." 4. "I need to add 0.5 ounce of mineral oil to my daily diet."

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

The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client should the nurse recognize as best supporting the diagnosis of gastric ulcer? 1. "The pain doesn't usually come right after I eat." 2. "The pain gets so bad that it wakes me up at night." 3. "The pain that I get is located on the right side of my chest." 4. "My pain comes shortly after I eat, maybe a half hour or so later."

4. "My pain comes shortly after I eat, maybe a half hour or so later." Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by food. The pain occurs a half hour to an hour after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

The nurse is caring for a client diagnosed with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times? 1. An obturator 2. A Kelly clamp 3. An irrigation set 4. A pair of scissors

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

A client diagnosed peptic ulcer disease and scheduled for a pyloroplasty asks the nurse about the procedure. The nurse should base the response on which information? 1. A pyloroplasty involves cutting the vagus nerve. 2. A pyloroplasty involves removing the distal portion of the stomach. 3. A pyloroplasty involves removal of the ulcer and a large portion of the cells that produce hydrochloric acid. 4. A pyloroplasty involves an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum.

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

A primary health care provider asks the nurse to obtain a Salem sump tube for gastric intubation. The nurse should correctly select which tube from the unit storage area? 1. A feeding tube 2. A jejunostomy tube 3. A Sengstaken-Blakemore tube 4. A tube with a larger lumen and an air vent

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

The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription should the nurse most question? 1 . Lorazepam 2. Furosemide 3. Omeprazole 4. Acetaminophen

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

The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription should the nurse most question? 1. Lorazepam 2. Furosemide 3. Omeprazole 4. Acetaminophen

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

The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse should conclude which is the problem and what action should be taken? 1. This is a serious complication; the primary health care provider must be notified immediately. 2. It is a normal occurrence for a nasogastric tube to stop draining; no action is required. 3. Thick gastric secretions may be blocking the tube; removing this tube and reinserting a new tube will correct the problem. 4. Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying.

4. Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying. The nurse must check nasogastric tubes regularly to maintain the tube's patency and ensure that it is draining properly. Nasogastric tubes are used to decompress the stomach. The gastric distention will be relieved only if the tube drains properly. One cause of improper tube drainage is that channels of gastric secretions form along the walls of the stomach and bypass the holes in the nasogastric tube. Turning the client regularly helps collapse the channels and promotes gastric emptying. The tube already has been flushed, so it is unlikely that it is still blocked by thick secretions. Although this is a problem that requires attention and intervention, it is not a serious complication.

The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse? 1. Antacids coat the lining of the stomach. 2. Omeprazole will coat the ulcer to help it heal. 3. Sucralfate changes the acidity of fluid in the stomach. 4. Cimetidine results in decreased secretion of stomach acid.

4. Cimetidine results in decreased secretion of stomach acid. Cimetidine and other histamine H2-receptor antagonists decrease the secretion of gastric acid in the stomach. Antacids neutralize acid in the stomach. Omeprazole inhibits gastric acid secretion. Sucralfate promotes healing by coating the ulcer.

A client receiving a high cleansing enema complains of pain and cramping. Which corrective action is most appropriate for the nurse to take? 1. Reassure the client and continue the flow. 2. Discontinue the enema and notify the registered nurse (RN). 3. Raise the enema bag so that the solution can be completed quickly. 4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.

4. Clamp the tubing for 30 seconds and restart the flow at a slower rate. Enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for approximately 30 seconds and restarted at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. The level of the solution should not be raised because this will aggravate symptoms. There is no need to discontinue the enema or notify the RN based on the information provided.

A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed? 1. Flat with the client prone for at least 60 minutes 2. Supine with the client in the left lateral position for 10 minutes 3. Elevated 45 to 60 degrees with the client supine for 15 minutes 4. Elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes

4. Elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes Aspiration is a possible complication associated with nasogastric tube feeding. The HOB should be elevated 30 to 45 degrees for 60 minutes following bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying, which also will reduce the risk of vomiting. The flat or supine position should be avoided because of the risk of aspiration.

After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse should monitor the client closely for which priority esophageal complication? 1. Varices 2. Necrosis 3. Rupture 4. Hemorrhage

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

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. The nurse should determine that which data would further support this diagnosis? 1. History of frequent intake of spicy foods 2. Frequent heartburn with a sour taste in the mouth 3. Complaints of stress with a history of chronic kidney disease 4. History of chronic obstructive pulmonary disease with weight loss

4. History of chronic obstructive pulmonary disease with weight loss History of chronic obstructive pulmonary disease is commonly associated with gastric ulcers, because this disease increases gastric acid secretion. Weight loss is also associated with gastric ulcer disease. The other options do not contain risk factors or symptoms commonly associated with this disorder. The symptoms listed in option 2 may be seen in gastroesophageal reflux disease. Spicy foods often have been blamed for ulcers, but this link has not been proven.

The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history should the nurse determine is least likely associated with this disease? 1. History of alcohol abuse 2. History of tarry black stools 3. History of gastric pain 2 to 4 hours after meals 4. History of the use of acetaminophen for pain and discomfort

4. History of the use of acetaminophen for pain and discomfort Unlike aspirin (acetylsalicylic acid), acetaminophen has little effect on platelet function, doesn't affect bleeding time, and generally produces no gastric bleeding. The data in options 1, 2, and 3, if reported by the client, are indications of peptic ulcer disease.

The nurse is assisting in planning stress management strategies for the client diagnosed with irritable bowel syndrome. Which suggestion is most appropriate for the nurse to give to the client? 1. Rest in bed as much as possible. 2. Limit exercise to reduce bowel stimulation. 3. Try to avoid every possible stressful situation. 4. Learn measures such as biofeedback or progressive relaxation.

4. Learn measures such as biofeedback or progressive relaxation. Treatment for irritable bowel syndrome includes stress reduction measures such as biofeedback, progressive relaxation, and regular exercise. The client should also learn to limit responsibilities. Other measures include increased fluid and fiber in the diet as prescribed and antispasmodic or sedative medications as needed.

A nurse organizing care for a client diagnosed with hepatitis plans to meet the client's safety needs by performing which action? 1. Bathing the client with tepid water and mild soap only 2. Assessing and recording the client's weight twice daily 3. Monitoring red blood cell and white blood cell counts daily 4. Monitoring prothrombin and partial thromboplastin values

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

The nurse is providing care for a client suspected of having appendicitis. Which priority intervention should the nurse anticipate will be prescribed for this client? 1. Full liquid diet 2. Clear liquid diet 3. Mechanical soft diet 4. No oral intake of liquids or food

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

A client arrives at the emergency department complaining of severe abdominal pain and is placed on NPO status. During a quick assessment the nurse observes that the client has both Cullen's sign and Grey Turner's sign and pancreatitis is suspected. The nurse should assist to implement which action first? 1. Place a nasogastric tube. 2. Hydrate the client with intravenous fluids. 3. Ensure the client receives intravenous pain medication. 4. Obtain vital signs and draw blood for laboratory analysis.

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

The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse should include which risk factor for colorectal cancer in the material? 1. Age of 20 years 2. High-fiber, low-fat diet 3. Distant relative with colorectal cancer 4. Personal history of ulcerative colitis or gastrointestinal (GI) polyps

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

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred? 1. Dark and bluish 2. Sunken and hidden 3. Narrowed and flattened 4. Protruding and swollen

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

The nurse should reinforce instructions to a client that has had a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information? 1. Most diets are deficient in all of the B vitamins 2. Once symptoms are evident, pernicious anemia is often fatal. 3. Symptoms can occur as long as 10 years after gastric surgery. 4. Regular monthly injections of vitamin B12 will prevent this complication.

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

The nurse should reinforce instructions to a client that has had a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information? 1. Most diets are deficient in all of the B vitamins. 2. Once symptoms are evident, pernicious anemia is often fatal. 3. Symptoms can occur as long as 10 years after gastric surgery. 4. Regular monthly injections of vitamin B12 will prevent this complication.

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

The nurse has assisted the primary health care provider with a liver biopsy, which was done at the bedside. Upon completion of the procedure, the nurse should assist the client into which position? 1. Left side-lying with the right arm elevated above the head 2. Right side-lying with the left arm elevated above the head 3. Left side-lying with a small pillow or towel under the puncture site 4. Right side-lying with a small pillow or towel under the puncture site

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

The nurse assigned to care for a client diagnosed with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing? 1. Sims' 2. Prone 3. Supine 4. Semi-Fowler's

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

A postoperative client has regained bowel sounds and is ready to start a clear liquid diet. The nurse is told that the primary health care provider has written a prescription to remove the nasogastric (NG) tube. The nurse assists in the procedure and should ask the client to do which during tube removal? 1. Breath normally. 2. Exhale until the tube is out. 3. Perform the Valsalva maneuver. 4. Take a breath and hold it until the tube is out.

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

The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to absorb food. While doing this, the nurse recalls that absorption is most concerned with which bodily function? 1. Removal by osmosis of digested food to the cells 2. The chemical process involving the breakdown of foods 3. The transfer of nutrients into the cell by active transport 4. The transfer of digested food molecules from the GI tract into the bloodstream

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

A primary health care provider asks the nurse to obtain a Salem sump tube for gastric intubation. The nurse should select which tube from the unit storage area? 1. Miller-Abbott tube 2. Sengstaken-Blakemore tube 3. Tube with just a single lumen 4. Tube with a lumen and an air vent

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

The nurse is evaluating the effect of dietary counseling on the client diagnosed with cholecystitis. The nurse determines the client understands the instructions given if the client states that which food item is most appropriate to include in the diet? 1. Beef chili 2. Grilled steak 3. Mashed potatoes 4. Turkey and lettuce sandwich

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

The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. When planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? 1. Offer small sips of water frequently. 2. Encourage the client to suck on sour, hard candy. 3 Use lemon glycerin swabs to provide oral hygiene. 4. Use diluted mouthwash and water to swab the mouth after brushing teeth.

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

The nurse is caring for a client with a diagnosis of pneumonia and a history of bleeding esophageal varices. Based on this information, the nurse should plan care knowing that which could most result in a potential complication? 1. Pain 2. Diarrhea 3. Frequent swallowing 4. Vigorous coughing

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

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin C 3. Vitamin E 4. Vitamin B12

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

The nurse is reinforcing discharge instructions to a client who has had a total gastrectomy. The nurse instructs the client about the importance of returning as scheduled to the health care clinic for which priority assessment? 1. Renal function studies 2. Gastric analysis studies 3. Vital sign measurements 4. Vitamin B12 and folic acid studies

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

A client diagnosed with chronic gastritis has been told that there is too little intrinsic factor being produced. The nurse should explain to the client that which therapy will be prescribed to treat the problem? 1. Antacid use 2. Antibiotic therapy 3. Vitamin B6 injections 4. Vitamin B12 injections

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

The nurse is preparing to administer a soapsuds enema to a client. Into which position should the nurse place the client to administer the enema? (refer to figure) A) Supine B) Prone C) Left side-lying Sim's D) Right side-lying Semi prone

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